
HHB 



MANUAL 



OP THE 



PRACTICE OF MEDICINE, 



A MANUAL 



OF THE 



PRACTICE OF MEDICINE. 



B Y 

GEORGE HILARO BARLOW, 

M.A. & M.D. CANTAB. 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; PHYSICIAN TO GUY'S HOSPITAL; TO THE MAGDALEN 
hospital; AND TO THE PHILANTHROPIC SOCIETY. 

\ 



WITH ADDITIONS, 



BY 



D. FRANCIS CONDIE, M. D., 

FELLOW OF THE COLLEGE OF PHYSICIANS; 
AUTHOR OF " A PRACTICAL TREATISE ON THE DISEASE OF CHILDREN, ETC." 




PHILADELPHIA: 
BLANC HARD & LEA. 

1856. 



t* 



<o 



"^<V* 



Entered according to Act of Congress in the year 1856, 

BY BLANCHARD & LEA, 

In the Clerk's Office of the District Court,, in and for the Eastern District of 

Pennsylvania. 



PHILADELPHIA: PRINTED BT KING & EAIRD. 9 SANSOM STREET. 



TO 

RICHARD BRIGHT, M.D., F.R.S., 

PHYSICIAN EXTRAORDINARY TO HER MAJESTY, FELLOW OF THE ROYAL 

COLLEGE OF PHYSICIANS, 

CONSULTING PHYSICIAN TO GUY'S HOSPITAL, 

ETC., ETC. 



TO 

THOMAS ADDISON, M.D., 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, 
SENIOR PHYSICIAN AND LECTURER ON THE PRACTICE OF MEDICINE 

TO guy's hospital, 

ETC., ETC. 



AND TO 

HENRY MARSHALL HUGHES, M.D., 

FELLOW AND CENSOR OF THE ROYAL COLLEGE OF PHYSICIANS, 

PHYSICIAN TO GUY'S HOSPITAL, 

ETC., ETC. 



®p» Waxl 



IS DEDICATED, AS A TOKEN OF ESTEEM, 
BY THEIR FAITHFUL FRIEND AND COLLEAGUE, 

THE AUTHOR. 



ADVERTISEMENT 
OF THE AMERICAN EDITOR. 



We are pleased that an opportunity has been afforded us of 
presenting to the physicians of the United States an edition 
of Dr. Barlow's "Manual of the Practice of Medicine." Of 
its favourable reception by them, we can entertain not the 
slightest doubt. We know, indeed, of none better adapted 
for the use of the student and young practitioner, and for oc- 
casional reference by those more advanced in the profession. 

Instead of a meagre and indistinct outline of the leading 
diseases which the physician may be called upon to treat, the 
author has, with great skill and accuracy, delineated their 
characteristic phenomena, their nature, causes, and remedial 
management, so as to give a clear and faithful representation 
of what may be denominated their natural history, as well 
as their proper treatment; in accordance with the latest ob- 
servations and the experience of the best medical authorities. 
By keeping constantly in view the recognized principles of 
general pathology and therapeutics, the reader is made aware 
of those varying circumstances which so frequently modify 
the character and progress of different cases of the same 
disease, as they present themselves in actual practice, de- 
manding, in consequence, a modification, also, in their treat- 
ment, or, the indications remaining the same, a change in 
the means by which those indications are to be fulfilled. 



8 ADVERTISEMENT OF THE AMEEICAN EDITOR, 

The practical portions of this manual are particularly 
excellent, as well for their clearness and precision, as for 
their conformity to the principles of a correct therapeutics. 
The position of Dr. Barlow as physician to one of the large 
London, Hospitals, and his intimate association with some of 
the most distinguished practitioners of that metropolis, has 
enabled him very fully to compare the rules of treatment ad- 
vanced with the results of actual observation and experience. 

The present edition is an exact reprint of the work as 
issued from the London press. The only important deviation 
from the latter is the rendering into English the directions 
appended to the several formulae given by the author. 

The chief additions that have been made by the American 
editor are, a chapter on Cholera Infantum, one on Cerebro- 
spinal Meningitis, and a third, on Yellow Fever. The few 
notes introduced into the text are distinguished by being 
inclosed between brackets, [ ]. How far these additions 
enhance the value of the work must be left to the judgment 
of the medical public. 

It is hardly necessary to remind the intelligent reader, 
that the terms hydrargyri chloridum, and liydrargyri bichlori- 
durn employed in the formulae given in the present work, 
are intended, the first for Calomel, — the hydrar. chhrid. mite 
of the U. S. Pharmacopoeia, and the second, for corrosive 
sublimate — the Jiydrar. chlor. corrosiv. of the U. S. Pharm. 

Philadelphia, January, 1856. 



PREFACE. 



Mr object in the present work has been to lay before my 
professional brethren, more particularly students and younger 
practitioners, a system of medicine based upon the etiology, 
or what I would venture to call— the natural history- — of 
disease. 

I do not, indeed, mean to imply that others have not pre- 
ceded me in the same course, and with distinguished success. 
The profound and philosophical " Outlines of Pathology and 
Practice of Medicine," of Dr. Alison ; the elaborate work on 
the " Principles of Medicine," of Dr. Williams ; the eloquent 
as well as logical and scientific lectures of Dr. Watson ; and 
the unfortunately as yet unfinished work of Doctors Bright 
and Addison, on the " Elements of Medicine," are more than 
sufficient evidence to the contrary. . 

Without, however, in the slightest degree, detracting from 
the merits of these and similar works; it is, I believe, 
admitted that we are at present in need of a hand-book for 
students. 

It is hardly to be expected, and perhaps not to be desired, 
that a professedly elementary work should abound in origi- 
nality, and therefore much that appears in the following 
pages must have been borrowed from others ; but it cannot 
fail to add weight to any doctrine, which I would inculcate, 
to be able to enforce it by other and better authority than 
mv own. At the same time I would add that, whatever 



10 PREFACE, 

is here advanced upon points of practice is mine, in so far as 
that I have compared it with my own observation and 
experience. I cannot, however, forbear to express my 
gratitude to Doctors Bright and Addison, of whom I have 
had the advantage of being the pupil as well as the honour 
of being a colleague ; and to my late colleague, Dr. Babing- 
ton, as well as to ail my present colleagues, for much that 
I have acquired orally. 

I am aware of many omissions, others will, no doubt, 
detect many errors. I trust, however, that upon questions 
of practice, I have advanced little that will not meet the 
concurrence of the enlightened members of our profession. 
Where, however, I have advocated opinions differing from 
those commonly entertained, I have stated my reasons for 
doing so. I fear that I have thus been occasionally led into 
discussions, which all must feel to be tedious, and some may 
reckon superfluous, but my excuse must be my anxiety, to 
the utmost of my ability, to connect not only practice, but 
diagnosis also, with principles; believing, as I do, that 
empirical diagnosis can lead only to empirical practice. 

I hope that I may not fall short of the expectations of my 
friends as much as I have disappointed my own, though in 
regard to the latter, I would fain console myself with the 
words of the great moralist, that " to rest short of his own 
aims is incident to every one whose views are comprehensive, 
and whose fancy is lively ; neither is any one satisfied with 
himself because he has done much, but because he can 
conceive little." 

Ukion Street, Southwark, 
October 23, 1855. 



CONTENTS. 



PAGE 

Preliminary Observations . . . . . .17 

I. Causes of Disease 18 

II. Modes of Death ....... 24 

III. Elementary Changes 29 

IV. Inflammation . . . . . . .30 

V. Signs of Inflammation, and of Disease in 

General .65 

YI. Fatal Termination and Treatment of Inflam- 
mation 82 

VII. Typhous, Scrofulous, and Tuberculous Deposits 106 
VIII. Eheumatic and Gouty Inflammation . . .115 

Gout 121 

IX. Auscultation . . . , '. . . . 129 
X. Cynanche, Laryngitis, Croup .... 138 

Laryngitis 142 

Croup 150 

XL Catarrh and Bronchitis 164 

Bronchitis . 168 

XII. Pneumonia and Pleuritis 186 

Pleuritis 205 

XIII. Phthisis 227 

XI Y. Diseases of the Heart and its Appendages . 255 

XV. Diseases of the Liver and its Appendages . . 293 



12 



CONTENTS. 



XVI. Diseases of the (Esophagus . 
XVII. Diseases of the Stomach 
XVIII. Dyspepsia . . 

XIX. Peritonitis 

XX. Enteritis and Obstructed Bowel 

Obstructed Bowel . 
XXI. Muco-Enteritis, Tabes Mesenterica, Diarrhcea 

and Dysentery 

[Cholera Infantum] 
XXII. Diseases of the Kidneys 

Nephritis . ... 

Bright's Disease 

XXIII. Urinary Deposits and Diabetes. 

Diabetes 

XXIV. Inflammatory Diseases of the Encephalon 

[Cerebro -spinal Meningitis 
XXV. Delirium Tremens and Mania . 

Mania 

XXVI. Apoplexy and Paralysis . 
Spasmodic Affections 

Asthma 

XXVII. Intermittent and continued Fevers. 
Intermittent Fever . 
Continued Fever 
XXVIII. Eruptive Fevers .... 
[Yellow Fever] 
XXIX. Epidemic Cholera 
XXX. Influenza and Hooping-Cough . 

Hooping-Cough 
XXXI. Diseases of Adolescence and Puberty 



PAGE 

313 
315 
326 
336 
356 
358 

365 
373 

378 
383 
386 
405 
416 
419 
433 
443 
447 
450 
468 
481 
485 
488 
501 
530 
554 
590 
596 
597 
598 



MANUAL 



OF THE 



PRACTICE OF MEDICINE. 



PKELIMINAKY OBSEKVATIONS. 

Medicine, in its present state, may be defined to be the art of 
detecting and discriminating disease by the symptoms accessible to 
onr investigations ; and of removing, checking, or allaying it, by the 
different means, at our disposal, for influencing the vital actions of 
the living body. 

This art then presupposes a knowledge of health, — that is, of the 
functions of the body, and the forces by which it is actuated ; of dis- 
ease, — that is, of the changes both structural and functional from the 
healthy state, and of the laws which regulate the sequences of those 
changes; and — of the action of external and internal agents and 
remedies, upon the system, both in health and disease. 

Now if the above sciences were perfect, medicine would consist in 
a collection of corollaries from the truths contained in them, since a 
knowledge of healthy structure and function would enable us at once 
to appreciate any departure from it, and a knowledge of the changes 
in structure and function, which constitute disease, and of the laws 
which regulate the sequences which those changes observe, which 
lead us at once to recognize the nature and origin of the disease; 
whilst a knowledge of the action of remedies would enable us at 
once to select and apply the most appropriate. 

But as at present these subsidiary sciences are by no means per- 
fect, there remains much which can only be learned by experience 
gained from the practice of medicine itself, and therefore medicine 
has its own truths and principles, which we cannot at present deduce 
from any other branch of knowledge. The theory of medicine must 
in fact still be regarded as an inductive science of itself, though we 
are at liberty to take for granted the established truths of those to 
which we have alluded, and in the following pages shall rarely enter 
into any examination of them, 

2 



18 CAUSES OF DISEASE. 



I. 

CAUSES OF DISEASE. 

The term cause of disease is often used in too vague a sense, being 
sometimes employed to express the lesion which is supposed to give 
rise to the morbid phenomena, at others to indicate the cause or 
agent which has produced the lesion in question, — at others, again, 
to describe the condition of the system, when exposed to that agent, 
and which has rendered it more than ordinarily susceptible of its 
influence. Thus, when a person presents certain symptoms which, 
upon further investigation prove to be connected with inflammation 
of the lun^s, that inflammation is said to be the immediate cause of 
the disease ; and if, upon further inquiry, it is ascertained that these 
symptoms have come on after unusual exposure to cold; that ex- 
posure is said to be th© exciting cause ; and, if it further appear that 
the patient had before been of a feeble or delicate condition from 
previous illness, intemperance, or other causes, this state of system, 
and sometimes also the causes which had led to it, are called the 
predisposing causes. ISTow, upon a little reflection, it becomes obvious 
that the term cause of the disease, does not strictly apply to either 
the first or the last of these. The so-called immediate proximate 
cause is, in fact, nothing but the disease itself, and therefore cannot 
be said to be the cause. The last again indicates merely a passive 
susceptibility, a thing widely different from any correct notion of an 
active cause. Again, to take another instance, marsh miasma or 
poison is well known to be the cause of ague, but persons who have 
been exposed to this miasma with impunity, when in perfect health, 
have become powerfully affected by it, when suffering from weak- 
ness induced by excessive fatigue, intemperance, or other diseases. 
Now these, as Dr. Abercrombie remarks,* were never known of 
themselves to produce ague, and therefore cannot be said to be its 
cause ; and although such a mode of speaking is not only admissible, 
but convenient in ordinary conversation, it is in the highest degree 
unphilosophical, and therefore inexpedient in the language of medi- 
cine, which though not strictly a science, is an art based upon science, 
and in which the meaning of the terms employed should be fixed 
with logical precision. 

We have then the disease itself, of which the symptoms are the 
effect, and of which some influence or agency, external or internal, 
disturbing the natural functions, is the true cause, though what its 
real nature may be, we are not always able to ascertain ; and lastly, 
we have the system, upon which this force or cause acts, and of 
which the condition must greatly modify the result produced ; and 
if previous disease or other debilitating agencies have impaired those 

* On the "Intellectual Faculties." 



HEKEDITAKY TENDENCY TO DISEASE. 19 

powers of the system, by which — injuries are repaired, — the de- 
pressing or other injurious influences of some poisons resisted, and 
others eliminated, we shall have a great susceptibility for various 
forms of disease, but not what can be called a cause of such disease. 

Although, however, we dissent from the propriety of calling, a 
susceptibility of being affected by morbific agents, a cause of disease, 
indiscriminately with those agents ; we are by no means disposed to 
disregard such susceptibility in any of our reasonings concerning the 
origin of disease, since upon it, must in many instances depend 
whether any disease will be produced, when an individual has been 
exposed to any specific or other cause of disease, and we are also 
willing to admit that this very susceptibility is often itself a disease, 
and that the very causes of this susceptibility may of themselves be 
real causes of disease. Thus we have stated that intemperance will 
render a person more susceptible of the action of marsh miasma; 
but this susceptibility is often associated with a structural change in 
some of the depurating organs, as the liver or kidneys, if it do not 
consist in it, and of which intemperance is a cause, and we know 
also that such, structural change may often constitute in itself a most 
formidable disease. 

The chief predisposing conditions which constitute a liability to 
disease, upon the application of the ordinary causes, are chiefly as 
follows : — 

(1.) An hereditary tendency to particular diseases, transmitted 
from parents to children. It is true, indeed, that all constitutional 
peculiarities in the parents, influence the offspring in a greater or 
less degree ; but this is more particularly the case with certain dis- 
eases, amongst which are scrofula and tuberculosis in all their varie- 
ties, — asthma, — diseases of the nervous system, especially epilepsy 
and mania, — gout, — gravel, — diabetes, — and several diseases of the 
skin. 

Now it is obvious that this congenital proclivity to particular dis- 
eases cannot be removed by art ; but if we also know, and can by 
any means obviate, the agents which are the causes of these diseases, 
we may often do much towards their ultimate prevention. 

(2.) But besides the above, which may be said to be congenital 
liabilities to disease, there are others, which, may be called the ac- 
cidents of the individual, such as casual occurrences, in the form of 
disease or otherwise, which, by impairing the power of the circula- 
tion, or depressing the nervous energy, render the system more sus- 
ceptible of any influence to which it may be subjected. Amongst 
these may be reckoned imperfect, unwholesome diet, especially during 
the period of infancy and youth ; — the habitual want of the natural 
stimuli of muscular exercise, fresh air, and light; — previous de- 
bilitating diseases, and excessive and repeated evacuations, either of 
the blood or of the serous part of it; — habitual intemperance, which 
produces chronic change in the organs of circulation, digestion and 
secretion, besides depressing the nervous energy: — these, like here- 
ditary predisposition, impress upon the system a susceptibility which 
is more or less permanent and constitutional. 



20 SPORADIC CAUSES OF DISEASE. 

(3.) The same causes, when acting only for a short time, may pro- 
duce a temporary and transient proclivity to disease; as may also 
long-continued exposure to cold, depressing passions, excessive exer- 
tions, and privation of sleep, protracted fasting; also exposure to 
excessive and long-continued heat, to impure air, as that of crowded 
or ill- ventilated rooms, or emanations arising from imperfect drain- 
age ; though these latter may often prove a direct cause of disease ; 
as also intemperance and excessive sexual indulgence, both which 
may induce disease without the intervention of any other morbific 
cause, as well as render the system more susceptible to the action of 
any such cause. 

Of the above agents, some affect more powerfully particular organs, 
and dispose them more than others to suffer from the application of 
any cause of disease; but, as Dr. Alison very justly observes, "there 
is no one organ or texture which is uniformly affected, nor any one 
kind of diseased action which is uniformly excited by these causes." 
Their general effect is to dispose the body to suffer from the exciting 
causes of inflammations, or other acute diseases, amongst which 
latter we may include the various morbific poisons which affect either 
particular individuals, or whole communities. We are thus led to 
a threefold division of the causes of disease ; into, 1st, Sporadic, or 
those affecting particular individuals; 2nd, Endemic, that is to say, 
continually, or at repeated intervals, affecting the inhabitants of a 
certain fixed locality; 3rd, Epidemic, powerfully, and often fatally, 
affecting for a time the population of certain districts or countries, 
and disappearing from them, to reappear again in other districts, or 
in the same district at some future period. 

Of Sporadic diseases the chief causes are, — 

1. Mechanical and chemical injury; which, however, fall mostly 
within the province of the surgeon. 

2. Yiolent muscular exertions, hurrying the movements of the 
blood, and thus, by disordering the circulation, favouring local con- 
gestions, and sometimes injuring some portion of the circulatory 
apparatus. 

3. Mental emotions, and intense sensations ; which sometimes dis- 
turb the action of the heart, or the circulation through the brain, 
and at others derange the secretions. 

4. Excesses of all kinds; which injure the secretions, and induce 
chronic disease of the secretory organs, and, by disordering the cir- 
culation, produce disease of the vascular system. 

5. Suppressed evacuations ; which induce plethora in any part of 
the system that may be predisposed to it: whilst excessive evacua- 
tions, by weakening the action of the heart, will sometimes produce 
the same result, and sometimes greatly influence the functions of the 
nervous and muscular systems. 

6. External heat; which may either irritate the part exposed to 
it, indirectly affect the nervous system, or disorder the general 
circulation. 

7. External cold — which often powerfully affects the nervous sys- 
tem, and greatly disturbs the circulation, producing active conges- 



EFFECTS OF HEAT AND COLD. 21 

tions and inflammations, and, by repressing the action of the skin, 
producing disease of those secretory organs to which the former is 
auxiliary — is one of the most frequent, perhaps the most frequent, of 
all the causes of disease. 

The effect of cold upon the part to which it is immediately applied, 
is rather to render it susceptible of diseased action, than directly to 
excite it ; this action evidently arising when the temperature is sub- 
sequently restored. It appears also, that the effect of heat or cold in 
producing intense sensation, or disturbance of the healthy action, 
is proportionate, not so much to the actual temperature, as to the 
rapidity with which change of temperature is induced. Thus, the 
application of the natural temperature of the body to a frost-bitten 
limb, will produce the same effect as a heat of 212° R, under ordinary 
circumstances ; and the effect of cold in producing internal disease is 
increased by previously heating the body ;* and, for a similar reason, 
it is greater when applied by drafts or currents of air, or by wet 
clothes, which rapidly carry off the heat of the body. Though, as 
Dr. Alison adds, "in the circumstance of moisture, and, perhaps, 
other occasional qualities of cold air, there seems to be a peculiarity 
not yet understood, as to this power of exciting inflammation." 

A languid state of the circulation, with the consequent diminished 
power of generating heat, increasing and prolonging the sensation of 
cold applied to the surface, favours its action in producing internal 
congestions; and it is probable, on this account, that during sleep 
the system is much more prone than at other times to suffer from 
the effect of cold. 

The effect of cold, in producing internal inflammations, is very 
remarkable when it is applied to parts largely supplied with sentient 
nerves, and which are ordinarily protected by warm covering or 
otherwise^ especially when compared with its effects upon other parts, 
similarly supplied with nerves, but not similarly protected ; thus the 
sensation, produced by cold applied to the feet of those who are com- 
monly warmly shod, is most intense, and apt to produce internal 
congestions, although the same individual may expose his hands to 
great cold without any ill effect, or even inconvenience. 

The depressing effects of cold may be resisted or greatly mitigated 
by a vigorous state of the circulation, which quickly restores the 
heat that is lost, and by a tone or power of endurance in the nervous 
system, which we can best describe, by characterising it as opposite 
to that which is induced, by a too careful exclusion of cold, and ap- 
plication of artificial warmth. This vigorous state of the vascular 
and nervous systems is promoted by habitual exercise and the oc- 

* [Persons 'who have been exposed to a high degree of atmospheric temperature, 
for any length of time, are more liable, all other things being equal, to suffer from 
exposure to cold, than those who are habitually accustomed to a much lower atmospheric 
temperature. Thus a sudden change in'the weather from warm to cold is almost invaria- 
bly productive of catarrh, pleurisy, and pneumonia. But by simply heating the body, 
short of inducing perspiration, in other words, by accumulating an amount of dry heat 
about the person, previously to exposure to cold, the effect of the latter in the produc- 
tion of disease will be diminished rather than increased. — Editor. "\ 



22 ENDEMIC CAUSES OF DISEASE. 

casional prudent application of cold, and a moderate nourishing 
diet. 

Again: there are causes of diseases, which can hardly be said to 
be endemic, but which act on large numbers, and with great violence 
at certain times and in certain places only, (generally by the introduc- 
tion of a poison by the jprimce vice, or, in some instances, by the lungs,) 
though their action is so slow that they are commonly reckoned as 
instances of disease. Of these we have instances, — in scurvy which 
attacks whole ships' companies, and it may be bodies of men on shore, 
when restricted to the use of salt provisions, and deprived of suc- 
culent vegetables, — in the palsy from lead, not only affecting painters, 
plumbers, and others, but also large portions of the community, when 
using water slightly impregnated with the salts of that mineral, de- 
rived from leaden pipes or cisterns. Another instance is to be found 
in ths pallid, doughy cachexia, so common in large towns, which is 
to be referred, in great measure, to the poison continually emanating 
from drains, cesspools, graveyards, and other sources of impurity 
abounding in such places, and which, probably, enters the system 
through the lungs ; though, no doubt, the want of radiant solar light 
greatly enhances the effect of such exhalations. After all, however, 
these are but cases of slow poisoning. 

Again we have causes of disease, which are, in the strictest sense, 
endemic fa 5^w), that is to say, affecting only the population of par- 
ticular districts, and that without any great variation as to particular 
seasons. Of this class of causes of disease are, that of the Bron- 
chocele, affecting the population of parts of Switzerland and Derby- 
shire ; of the Cretinism of the Alps ; of the Elephantiasis of Egypt. 

There is another class of causes of disease of great importance, at 
times extensively and fatally prevalent, affecting for a time, the 
population of certain districts; the disease thus produced being of a 
definite character, and, one which may with tolerable certainty be 
ascribed to a specific poison. 

Such diseases are said to prevail epidemically Qno fo^w), from their 
coming, for a time, upon the people of a certain country or district, 
which is at other times perfectly free from them. The causes of 
some of them are, however, in one sense of the word, strictly en- 
demic, that is to say, arising from the circumstances of the locality, 
so that although the disease in question may only prevail at certain 
times in a particular district, yet it is liable to recur epidemically in 
that district, and cannot affect other districts indiscriminately, but 
only such as resemble it. Of this form of epidemic disease, we have 
an instance in the agues which, at certain seasons, prevail in marshy 
districts, the cause of the disease being in such cases endemic, and 
consisting in a miasma produced by the emanations from decaying 
vegetable matter. Other diseases, again, affect whole populations 
with great rapidity, continuing their influence for a limited time, 
and affecting, in rapid succession, different districts, between which 
there can be discerned no points of resemblance which can be as- 
signed as causes of the disease; their outbreak in any locality not 
being to be accounted for by communication with persons from 



EPIDEMIC CAUSES OF DISEASE. 23 

infected districts. Of this form of endemic canse of disease, the in- 
fluenzas which have prevailed, at different times, without regard to 
place or season, form a good illustration. 

Other diseases again prevail epidemically, but which may be 
clearly traced to communication with infected persons ; though there 
can be little doubt that in the majority of cases, their diffusion is 
promoted by some circumstance affecting the population generally. 
Such diseases are contagious. Though by the term contagion we do 
not imply exclusively immediate contact by touch, but also mediate 
communication, as by means of the clothes, — the excretions, — the 
breath, or other exhalations. 



24: DEATH FROM SYNCOPE — COMA. 



II. 

MODES OF DEATH. 

There are few more important considerations in the treatment of 
diseases which, threaten life, than that of the manner of their fatal 
termination when they end in death. The different modes of dying 
were first explained by Bichat, in his celebrated " Recherches sur la 
Vie et la Mortf 1 but the subject was first treated of in reference to 
disease by Dr. Alison, of Edinburgh, and has since been elaborated 
with much perspicuity and elegance by Dr. Watson, in his beautiful 
lectures. A few short and simple reflections will, however, be suf- 
ficient for our present purpose. 

The different modes in which life ceases are through the suspension 
of the two primary vital functions, circulation and respiration. Of 
these, the former cannot be suspended, in the human subject, for 
more than a few seconds, and the latter for more than three minutes, 
without life being extinguished. 

We perceive then that there are two simple modes of dying: 
I. Death from failure of the heart's action, or, to speak more com- 
prehensively, death from failure of the moving powers of the circula- 
tion, which is technically termed syncope ; II. Death from impedi- 
ment to the aeration of the blood in the lungs, or death from apncea. 

I. Death from syncope, or death from the heart, may be produced 
either (1) from a sudden shock to the nervous system arresting the 
heart's action; or the same effect may be produced by weakness of 
the organ itself. The anatomical characters of this form of death by 
syncope are full cavities of the heart, with the dark blood on the 
right side, and the crimson arterial blood on the left. (2), By sudden 
or gradual abstraction of the vital stimulus of the heart, as in the 
case of violent haemorrhage or its more gradual drain by slower ab- 
straction of the blood, from more gradual exhaustion or failure of 
nutrition, continued discharges, or failure of nutrition as in death 
from inanition ; cases, too, occasionally occur which render it probable 
that death from failure of the heart's action may be induced by arrest 
of the extreme circulation cutting off the supply of blood from that 
organ, this may be termed peripheral syncope. The anatomical 
characters of this mode of death are, in extreme and rapid cases, 
empty ventricles, pretty firmly contracted ; and in cases where death 
has taken place more gradually, flaccid, but not empty ventricles. 

II. The second mode of death may ensue, (1,) when injury to the 
nervous system paralyses the movements of respiration, causing what 
is termed death by coma, or death beginning at the brain; and 
(2), by obstruction to the circulation through the lungs, constituting 
what is more strictly termed death by asphyxia, or death by apnoea. 
The anatomical characters of death from impeded pulmonic circula- 
tion, are full cavities, those of the right side of the heart being more 



SYNCOPE. 25 

particularly so, the blood being very dark in the latter, and in the 
former, of an almost venous hue. 

It is into these two modes of arrest of the vital functions, that all 
the different forms of death arising from injury or disease ultimately 
resolve themselves, although the manner of death, in many, or in 
most, may not be entirely simple ; so that the two causes of death 
may both be more or less in operation. It will, however, almost 
always be found that one or other predominates. 

I. Death from syncope, produced by a sudden shock, may arise, 
though rarely, from injuries inflicted upon the substance of the 
nervous centres, although it has been found that the integrity or 
even existence of the latter is not essential to the functions of organic 
life, as these may be continued when the brain or spinal marrow 
have been gradually removed or destroyed. Still, if a violent injury 
is suddenly inflicted upon the cervical portion of the spinal marrow, 
or upon the medulla oblongata, immediate death by syncope is the 
result. It is also through the influence of the nervous system, that 
mental emotion, as the sudden announcement of distressing intel- 
ligence, has sometimes proved fatal. And, in the same way, a shock 
may be carried from the extremities of the incident nerves to the 
nervous centre, and be reflected to the heart, by violent extensive 
injuries, especially those which involve an extent of surface largely 
supplied with sentient extremities of nerves; and the same thing 
occurs from wounds or other injuries of the abdomen, as well as 
from spontaneous disease of great intensity occurring in the same 
region, particularly near the situation of the solar plexus ; the depres- 
sion of the heart's action being in the case of disease less sudden, 
and the fatal syncope when it does take place, coming on gradually. 

Death from the heart may also take place from weakness of the 
organ itself, the walls of the heart having become attenuated or 
otherwise weakened by disease, or its ventricles dilated to an extent 
greatly disproportionate to their thickness; or a sudden stress may 
be thrown upon one of them (the left ventricle most commonly) by 
some sudden injury, as happens sometimes when there is laceration 
of the sigmoid valves. 

It is probably through the impression produced upon the extremi- 
ties of the nerves, that certain poisonous substances, as the woorara 
or upas-tree poison, produce death by stoppage of the action of the 
heart. 

The heart's action may also fail with greater or less rapidity from 
the abstraction of its natural stimulus, the blood ; as happens in 
violent haemorrhages : and more gradually in wasting discharges, in 
diseases of the organs of digestion impairing nutrition, and in death 
from starvation. 

Death from syncope includes the most sudden deaths, as when the 
life is extinguished by — violent concussion of the brain, — sudden 
extravasation of blood in the medulla oblongata, — sudden crushincr 
of the medulla spinalis, from violence or from sudden dislocation, 
arising from disease of the ligaments of the cervical vertebrae, those 
especially of the atlas and dentata. Death, also, produced by disease 



26 APXfflA — COMA. 

of the heart is well known to be amongst the most sudden, and in 
snch cases the death is by syncope. Death from failure of the heart's 
action is not, however, necessarily so sudden ; for though very violent 
haemorrhage may produce very speedy death, the death, in most 
cases, even of severe haemorrhage, is more gradual, and is preceded 
by pallor, clammy sweats, irregular pulse, and insensibility; with 
these symptoms are frequently conjoined others more directly refera- 
ble to the nervous system, arising from the diminished supply of 
blood to the brain : amongst which are nausea or vomiting, restless- 
ness, and jactitation or transient delirium, irregular sighing respira- 
tion, gasping, and convulsions. 

But death from failure of the heart's action may take place still 
more gradually, and it is then strictly termed death from asthenia; 
of this, the most perfect instance occurs, in death from inanition or 
starvation, which leaves both ventricles flaccid, but as nearly empty 
as after death from rapid haemorrhage ; and the same thing happens 
when death supervenes upon diseases impairing digestion and nutri- 
tion, or upon others which obstruct the renewal of the blood as it is 
expended to supply the waste of tissues ; or this kind of death may 
be brought about by destructive diseases causing exhausting dis- 
charges, or extensive suppuration. 

Certain poisons, of which we have specified that of the upas-tree, 
appear to produce sudden failure of the heart's action, that organ 
being found full, but, as it were, unable to contract upon its contents ; 
but on the other hand, we have an instance in sudden death from 
digitalis, of the ventricles being found contracted and empty, which 
certainly seems to favour the notion of the blood being delayed in 
the extreme circulation, rather than of a loss of power in the heart 
to propel it. 

II. Death from obstructed respiration may, as already pointed out, 
be two-fold — (1) death from apnoea, properly so called ; and (2) death 
from coma. 

(1.) The first of these takes place when an animal is killed by the 
exclusion of air from the chest, or by restraining the movements by 
which the respiration is carried on, or obstructing the passage of the 
blood through the lungs, by impediment to the circulation through 
the heart. Of the above we have evidences in drowning, strangling, 
suffocation, violent pressure upon the wails of the chest and abdomen, 
so as to stop both the expansion of the chest and the descent of the 
diaphragm ; or when in disease these movements are stopped by para- 
lysis, which occurrence belongs more commonly to the next form, or 
death by coma, but which may occur without the stupor which 
characterizes the latter. This form of death may also arise when 
the access of the blood, in the lungs, to a sufficient supply of oxygen 
is prevented by other gases, such as hydrogen, which, though not 
poisonous, cannot support respiration, and it may be caused in dis- 
ease by closure of the larynx or trachea; and by those diseases, 
whether of the bronchial tubes or lungs, which prevent the free 
access either of the air to the air-cells, or of the blood to the vessels 
which ramify between and around them, as well as by those which 



EFFECT OF POISONS. 27 

exclude both air and blood from the lungs, as is the case with large 
effusions of serum into the substance of the lungs, or into the pleural 
cavities. It may be produced also by stagnation or stoppage of the 
blood in the lungs by disease of the left side of the heart. 

The anatomical characters of this mode of death are, a very great 
engorgement of the cavities on the right side of the heart, and the 
presence of venous blood in those of the left side. The right side, it 
should be observed, is always the most engorged of the two, the left 
being in some instances comparatively empty, and that too in cases 
where there would appear to have been no mechanical obstruction to 
the pulmonic circulation, as when hydrogen or other gases have 
been inhaled which, though not poisonous, will not support respira- 
tion ; showing that by a want of the access of oxygen a congestion 
takes place in the capillaries of the lungs, even though the respira- 
tory movements and expansion of the lungs may be continued. 

(2.) Death from coma, or death from the brain, is in its ultimate 
result the same as death from apncea; but there is this difference, 
that in the former case aeration of blood in the lungs is impeded by 
a loss of its proper irritability in that part of the nervous system 
whence the nerves of respiration have their origin. The anatomical 
characters, therefore, as regards the lungs and heart are the same, 
the lungs being congested, the right side of the heart gorged with 
blood, and the left side circulating venous blood. It is in this way 
that effusion of blood or serum into the substance or the ventricles 
of the brain or upon its surface, causes death ; and it is in this way 
that many poisons, whether taken into the system from without or 
generated within it (and which are denominated morbid poisons), 
induce the same result. Of the poisons, the true narcotic ones pro- 
duce death in this manner, and such poisons act more slowly than 
some which produce death by syncope, from a shock, as it were, or 
sudden impression upon the nerves. Morbid poisons, among which 
may be classed excrementitious substances, such as bile and urea, 
produce death generally by coma, that is to say, by their acting, as 
poisons, on the brain ; but they may also, especially the latter, when 
in great quantities, act as sedatives to the heart. 

As regards the action of poisons, there has been a good deal of 
difference amongst physiologists, and a great many experiments, ap- 
parently contradictory, have been performed, mainly with a view of 
determining the question whether poisons, — by being taken into the 
circulation and conveyed to the brain, destroy life by extinguishing 
sensibility, in which case the mode of death ought necessarily to be by 
coma; — or whether they operate before they reach the nervous cen- 
tres upon the sentient extremities of the extreme nerves. Now, as 
we have seen that the modes of sudden or speedy death may be 
various, according as it takes place from the heart, the lungs, or the 
brain, so it is but reasonable to expect that the modes of death from 
poisons may be so likewise ; and that as violent injuries will some- 
times produce death by syncope from a shock to the system, or 
violent impression upon the extreme nerves; so some very powerful 
poisons will act in the same way, and that, obviously without any 



28 EFFECT OF POISONS. 

need for their being taken up into the general circulation ; whereas 
others, amongst which are poisonous gases, may obstruct the circula- 
tion through the lungs, and produce death from apncea ; whilst others 
again, like the narcotic poisons, produce death by coma, and must, 
therefore, in the generality of - instances, act only after they have 
been absorbed. But further than this, these poisons, several of them 
at least, act differently according as the dose is great or small, and 
according to the susceptibilities of the individual. Thus some poi- 
sons, as opium or alcohol, which will, in certain doses, produce coma 
after excitement, will, in larger ones, produce instant death, either 
arresting the moving powers of the circiilation by the powerful im- 
pression upon the nerves of the stomach, or producing immediate 
coma without excitement, so that we need be at no loss to account 
for the different results as regards the time and manner of death 
recorded by different observers when experimenting with different 
poisons. 

The necessary inference, however, appears to be, that as different 
injuries will produce death in different ways, by acting either upon 
the heart or the nervous system: and as the same difference may be 
observed in regard to injuries similar but differing in intensity, so 
different poisons may act either upon the nervous centres after ab- 
sorption, or more directly upon the moving powers of the circulation 
by the impression produced upon the sentient extremities of the 
nerves, and that the same difference may be observed in the mode 
of death from the same poison, according to the amount of the dose 
and the manner of application. 



ELEMENTARY CHANGES. 29 



ni. 

ELEMENTAKY CHANGES. 

Certain changes or deviations from trie healthy state may take 
place in the proper elements of a part, which although they may not 
be appreciable as disease, or become special objects of treatment, are 
nevertheless of importance as constituting the first steps towards 
those conditions which we more certainly recognise as such. 

Irritability, or the capability of contracting upon the application 
of a stimulus, is the distinctive property of muscular fibre, and may 
be regarded as one of the simplest manifestations of vitality in the 
living body. 

This irritability may become excessive: producing, 1, undue 
strength, or violence of muscular contraction; 2, over-readiness to 
contract, or susceptibility of being excited by too slight a stimulus ; 
3, unusual persistance of contraction, constituting tonic spasm or 
cram p. 

Irritability may be defective: 1, from a deficiency of strength of 
muscular contraction ; 2, from a slowness or sluggishness of contrac- 
tion under the ordinary or appropriate stimulus. 

Tonicity, or the tendency to slow moderate contraction, not neces- 
sarily terminating in relaxation, is a property not only manifested 
by the obviously muscular structures, but also by some others not 
generally accounted so, as the air-tubes and the middle coat of the 
arteries, giving them a tendency to contract upon their contents. In 
many respects tonicity appears to be closely allied to irritability, and 
it is, in the main, excited by the same agent, but with this remarka- 
ble exception, that cold increases tonicity and impairs irritability, 
whilst heat, which diminishes tonicity, although it relaxes the muscles, 
renders them, at the same time, more irritable. 

Tonicity may be excessive : when this is the case the muscles are 
disposed to be rigid, the pulse hard, owing to the contraction of the 
cavities of the heart being vigorous, and the contractile or resisting 
power of the artery considerable; the capillary circulation also is 
active, and the secretions are scanty, especially that of the skin, which 
is dry and hot. 

Tonicity may be defective : when this is the case the muscles are- 
lax and flabby, though their irritability may be in excess ; there is 
tremulousness, and the heart's action is feeble, though irritable ; 
owing to the diminished tonicity of the arteries, they readily yield 
to the injecting force of the left ventricle, and the pulse, though soft, 
is generally full : the extreme circulation is feeble ; the secretions 
are irregular, being either deficient, through the languid circulation 
in the secreting organ, or profuse and watery, owing to the relaxed 
condition of the vessels. 

Another element of disease in the dynamical condition of a part, 



30 ELEMENTARY CHANGES — BLOOD. 

appears to be an alteration in the relation between the tissues and 
the blood. That some such change is likely to take place, may be 
inferred from the analogy of health, since it is the condition of the 
part, rather than that of the artery supplying it, which determines 
the amount of blood which it receives as well as the activity of the 
circulation through it: the conditions upon which this mutual rela- 
tion depends, are not sufficiently understood, to enable us to explain 
its alterations; and we must therefore regard these alterations as 
ultimate facts. 

Disturbances of the nervous influences of the part, or as they are 
termed by Andral, lesions of innervation, constitute another primary 
element of disease. It is true, indeed, that, in by far the greater 
number of instances, these alterations of the nervous force originate 
in changes in the brain or spinal cord, or in the large nervous trunks ; 
yet, in these cases the disturbance thus produced, may set up fresh 
morbid action in the parts to which the ultimate filaments of the 
nerves are distributed : but further than this, there is reason for be- 
lieving that, besides being propagated to them, morbid changes may 
commence in the nervous fibrils themselves, these changes producing 
in their turn, alterations in the circulation and nutrition of the 
nervous centres. 

The blood, again, may undergo changes in its physical, chemical, 
and vital properties, and these changes constitute another class of the 
primary elements of disease. 

Among the most important of these changes, are the alterations in 
the proportions of its healthy constituents. 

The red corpuscles of the blood may exceed the healthy standard 
in quantity ; a circumstance which is generally observed in a state of 
the system, commonly described, as plethora. The proportion of 
these corpuscles, in health, is from 120 to 130 per 1000 ; but in this 
condition, they are found to amount to as much as 135 to 160 per 
1000. The blood in such cases, is remarkable for its deep colour; 
the clot is large and of a very moderate firmness, and is never buffed, 
owing to the small relative proportion which the fibrine bears to the 
corpuscles ; the serum also remains more or less coloured, after the 
coagulation has been completed. 

The red corpuscles may, on the other hand, be defective in quan- 
tity, this occurs in the state generally known by the term anaemia 
(want of blood, a and at^a), a word for which it has been proposed to 
substitute spanasmia (poverty of blood, waves and a^a) as more strictly 
expressing the real condition of the fluid ; in this state, the red par- 
ticles only are affected, the fibrine and solid contents of the serum 
retaining their normal proportions; thus, in the earlier period of 
spontaneous anaemia, and in its milder forms, we find the quantity of 
red corpuscles to be about 100 per 1000, and in the more advanced 
or severer cases, as low as 65 or even 30. The physical properties 
of the blood are in accordance with what might be expected from 
the deficiency of the corpuscles. After it has been allowed to flow 
freely, and left to coagulate, we find a small clot floating in an 
abundant colourless serum ; the clot is remarkably firm, and it is by 



CHANGES IN CONSTITUENTS OF BLOOD. 31 

no means uncommon to find it covered by a distinct buffy coat, pro- 
duced, as we shall hereafter have occasion to explain, by the excess 
of fibrine relatively to the corpuscles, the effect being the same, 
whether this excess arises from the increase of the former, or the 
diminution of the latter. 

Besides the variation in quantity, the red particles are liable to 
structural change, in disease. Thus in scurvy and Walcheren fever, 
the blood has been described to be of a pitchy blackness, arising, no 
doubt, from change in the colouring matter of the corpuscles. There 
may also be a breaking up of these corpuscles, and solution of the 
colouring matter, shown by its staining, not only the blood vessels, 
but some of the surrounding textures into which the entire corpuscles 
could not have transuded. They also undergo alterations in form 
and size, which, however, most probably arise from alterations of 
the liquor sanguinis, or medium in which they are placed. It was 
observed by Hewson, that pure water caused them to swell, whilst 
they shrunk in strong saline solutions; changes which are now 
generally understood to be brought about by endosmosis and exos- 
mosis, the surrounding medium causing fluid to pass in or out of the 
cell, according as it is of less or greater density than the fluid which 
the cell contains, which fluid must, in health, necessarily be of the 
same density as the serum. The red particles may also under dis- 
ease, lose their capability of changing from the venous to the arterial 
hue, by the action of oxygen. 

Alterations in the fibrine occur both as to its quantity and its 
physical and vital properties. The mean proportion of fibrine in the 
blood is, according to Andral, 3 per 1000, though other observers 
have estimated it somewhat lower. The proportionate quantity of 
this principle undergoes extensive changes in disease; it may be 
increased, in inflammatory diseases, to as much as 6, or even 8 per 
1000, whereas in some diseases of debility, as for instance, low 
typhoid fever, it may be reduced so low as one and a-half or one 
per thousand. 

Besides these changes in quantity there are others still more im- 
portant in the quantities of the fibrine. Of these qualities the most 
remarkable is its property of passing from the fluid to the solid 
form, by which the coagulation of the blood is produced; and the 
changes which occur in this process of coagulation in connection 
with diseased action are among the most interesting of morbid phe- 
nomena. " Within a few moments after emission, the blood, in the 
natural state, divides itself into a yellowish fluid called serum, and a 
dark red spongy mass called crassamentum* The time occupied by 
the separation of the clot, as well as the appearance which it presents 
when formed, varies in different conditions of the system. The time 
may be from 1 J minute to 15 or even more, though the causes in- 
ducing this acceleration and retardation have not been very clearly 
ascertained. The coagulation appears to be hastened by the oxygen 
in the atmosphere, and it may be greatly retarded by its exclusion, as 

* Alison's " Outlines of Pathology." 



32 CHANGES IN BLOOD — BUFFY COAT. 

when blood is drawn into a vessel of oil;* Again, it is well known 
that the artificial addition of many salts to the blood retards its 
coagulation hence we may conclude that a slow coagulation may 
depend upon an increase of the salts. 

Independently, however, of these considerations, the time occupied 
by the coagulation appears to be influenced by the quantity of the 
fibrine, for if the amount of this principle be larger than ordinary, 
the time which elapses before coagulation is increased, and the co- 
agulum possesses an unusual degree of firmness : and in general 
when the fibrine is abundant the clot is firm, and the coagulation 
slow, and when the fibrine is scanty the clot is loose and the coagula- 
tion speedy, as is the case with the last portion of the blood which 
flows when an animal is bled to death, f 

Again, it is to be remembered also that the corpuscles of the blood 
are of greater specific gravity than its other ingredients, and conse- 
quently these bodies must, when the blood is at rest, have a tendency 
to sink towards the bottom of the vessel. This tendency is, in a 
great measure, counteracted in healthy blood by the corpuscles be- 
coming entangled in the meshes of the fibrillating fibrine forming 
the clot, and even then its lower portion is of a deeper colour than 
the upper. If, however, it happen that the blood is longer in coagu- 
lating, or the corpuscles subside more rapidly than in the healthy 
state, we shall have the upper part of the clot free from corpuscles or 
nearly so, to a greater or less depth, and forming what is familiary 
known as the buffy coat. This network of fibrine, free from red 
particles, frequently continues subsequently to its coagulation, to 
undergo a slow contraction, by which the edges of the clot are drawn 
towards each other, giving its upper surface the concave appearance 
commonly denominated " cupped." 

To sum up what has been said ; the formation of the buffy coat is 
promoted, 1st, by an increase in the proportion borne by the fibrine 
to the red particles, whether that increase depend upon an excess of 
the former, or a defect of the latter; 2, by the time occupied in the 
coagulation of the blood, which time is increased by an increase in 
the salts, and an increase in the quantity of the fibrine ; 3, by the 
rapidity with which the red particles subside through the coagulating 
liquid, which may be increased by a diminution of the specific gravity 
of the serum, and also by an arrangement which they seem under 
some circumstances to affect, viz., a coalescence in considerable num- 
bers, having their flattened discs opposed to each other, like rouleaus 
of coin, which force their way through the semiviscid fluid by their 
aggregate weight more quickly than they could do singly. 

The size of the clot is in the inverse proportion to its firmness, 
and in the direct proportion to the quantity of fibrine ; so that, when 
the clot is loose, it may be apparently large ; although the quantity 
of fibrine may not be great : a large and firm clot, however, indicates 
a large proportion of fibrine, and a great amount of fibrillating or 

* Dr. Babington in Med. Cbir. Trans., vol. xvi. 
f Carpenter's " Manual of Pbysiology." 



COAGULATION OF BLOOD. 33 

contractile force, and when this force is in excess, depending pro- 
bably upon increased tonicity, the continued contraction of the flbrine 
forming the bufry coat gives it the cupped appearance. 

An important practical inference may be drawn from the above 
statements, viz., — that the buffy coat is not of itself a certain sign of 
any particular condition of the blood, since it may be produced by 
several different, and, in some respects, opposite causes. 

The proportion of dry albumen in healthy blood is about 70 or 80 
per 1000 ; under some circumstances of disease, probably in inflam- 
matory fever, it may be increased ; and the same may happen (pro- 
portionately to the fluid constituents of the blood) when a large 
quantity of water is carried rapidly out of the system, as in spas- 
modic cholera. This principle is reduced in quantity sometimes as 
low as 60 or 50 per 1000, or even lower, when a considerable amount 
is carried off by the urine, or repeated haemorrhages, or other ex- 
hausting discharges. It is possible that it is also deficient in cases 
of imperfect digestion or sanguification. 

The proportion of oily or fatty matter in the blood has not been 
accurately ascertained, and it probably undergoes great variations in 
health ; being generally the greatest about four or five hours after a 
full meal, its presence being indicated by an oily or milky appear- 
ance of the serum. 

The proportion of the salts of the blood is also liable to increase 
or diminution, and this variation, no doubt, plays an important part 
in many pathological phenomena. An excess of the salt retards, as 
we have already seen, the coagulation of the flbrine, and when very 
great prevents it altogether. A decrease in the quantity of these 
substances tends, according to Henle, to favour the adhesion of the 
corpuscles to each other ; and is stated by him to exist in inflamma- 
tory affections. The same deficiency is said by Stevens and others 
to be present in pestilential fevers and cholera. 

Independently of the variations in its natural ingredients, the 
blood may also undergo morbid alterations, from the presence of 
excretory matters not belonging to it in health, or, if so, not in ap- 
preciable quantities. 

Now we know, from physiology, that there are various matters, 
the products of the interaction of the tissues and the blood, which 
are in health speedily eliminated, and we also learn, from observa- 
tion of disease, that if these matters are not thus removed, they re- 
main in the blood, and act as poisons. 

The most important substances of this character, and those with 
which we are most concerned; in the treatment of disease, are the 
principles of the secretions of the great depurating organs, the lungs, 
the liver, and the kidneys, to which may, perhaps, be added the skin 
(which is, in a great measure, vicarious of the latter), and the glanchilae 
of the large intestines. 

Now the depurating action of these organs may be suspended or 



34 RETAINED SECRETIONS. 

interrupted chiefly in three different ways : 1st, the depurating organ 
may itself be nnsound ; 2, the circulation of the blood through it 
may be obstructed; or, 3, the matter to be eliminated may not be 
brought to the depurating organ in the particular form suited for 
removal by that organ. 

The first of these conditions will be specially noticed in respect 
to each secretion, in treating of the diseases of the corresponding 
organ, when the particular consequences of the retention will also be 
described. 

In order to the due appreciation of the second and third circum- 
stances just mentioned, as interfering with the action of the depurat- 
ing organs, it is necessary to understand the general conditions 
essential to their full operation. 

We know from physiology, that in the course of the circulation 
carbonic acid gas is formed and received into the blood, and that, if 
retained, it acts as a poison to the system ; and we also know that 
the removal of this gas is effected in the cells of the lungs, where it 
is exposed to the action of another gaseous fluid, the atmospheric air, 
which acts as a solvent of the carbonic acid, and, according to Dr. 
Stevens, exercises some attraction for it. 

It may here be remarked that, though water and carbonic acid are 
the only excretions or exhalations from the membranes of the air- 
cells in the perfectly normal state, yet, as is remarked by Dr. Alison, 
it is certain that many volatile matters taken into the stomach, are 
excreted unchanged or but little changed, with the breath, and pro- 
bably the body is thereby saved from their injurious effects. It 
must therefore follow, that if the free access of air to the cells or the 
free circulation of the blood through the lungs be impeded, there 
must ensue an inquination of the blood by carbonic acid and perhaps 
other gaseous excretions. 

As regards the bile and the urine, the former of these secretions is 
a liquid consisting of water holding in solution certain principles 
containing a large proportion of carbon and hydrogen, which are 
uniformly present in health, and are in part, though probably not 
wholly, excrementitious. These principles, moreover, exist in healthy 
blood in very minute quantities, and it is the oflice of the liver to 
remove them; their secretions taking place, as there is every reason 
to believe, from the minute branches of the portal vein, by means of 
the hepatic cells, and consequently an inquination of the blood, by 
these substances, must ensue, if the function of the liver be suspended, 
or the circulation of the blood through that organ be impeded. 

The presence of the bile pigment gives to the serum a yellow hue, 
which is another instance of change of colour in the blood; which 
change is also imparted to the surface, constituting the well-known 
jaundiced tint. 

The urine, again, is a liquid consisting of water, holding in solution 
various solid matters, which may be divided into two classes : 1, those 
lower organic products abundant in nitrogen, formed probably in 
the extreme circulation by the reciprocal action of the arterial blood 
and the organs of the body on each other, as the urea, uric acid and 



RETAINED SECRETIONS. 85 

water ; and 2, those soluble substances which are taken with the 
ingesta, and which do not undergo decomposition in passing through 
the system, as for instance, neutral salts formed by inorganic acids, 
The matters of both classes, when allowed to accumulate in the 
system, producing injurious effects ; the former probably as direct 
poisons, and the latter, by giving rise to changes of the blood already 
noticed (pp. 33, 34 ;) and both are carried off by the kidneys. 

Of the diseases of the liver and kidneys interfering with their 
secreting functions, we shall speak hereafter ; but it may here be 
remarked, although the proposition is almost self-evident, that — if 
there be not a free passage of blood through these organs, the con- 
tinual abstraction from that fluid of excrementitious matters cannot 
proceed; whether this impediment arise from venous obstruction 
distal to the organ, or pressure upon the afferent vessel tergal to it. 
Thus, in the case of the liver, obstruction to the return of the blood 
through the cava, or to the passage into the gland from the vena 
portaB, would alike interfere with the due secretion of bile. 

It is not, however, sufficient that the excreting organ be healthy, 
and that there be no impediment to the passage of the blood through 
it, but since the liver, and the kidneys, and also the skin, are adapted 
to secrete only liquids, it follows that the elements of the bile and 
also of the urine, cannot be removed unless they are brought to their 
respective secreting organs in a state of solution ; therefore a con- 
tinual supply of water is necessary for the depuration of the blood, 
and obstruction to that supply must give rise to the inquination of 
the latter by the elements of the secretions of these organs. 

The course of the water fulfilling this office is as follows. That 
which is received into the stomach is, with such soluble matters 
contained in it as are not decomposed in the primce vice, taken up by 
the capillary branches of the veins, which converge to form the vena 
portce, carried onwards with the blood through the trunk of that vein, 
and again dispersed by its ramifications through the liver ; here a 
portion of it is again separated from the blood, in order to form a 
solvent for the solid contents of the bile. Passing onwards through 
the pulmonic and systemic circulations, the redundant water of the 
blood carries with it those inorganic soluble matters which it con- 
tained at first, and receives, or rather acts as a solvent to those pro- 
ducts of the interaction of the blood and the tissues which have been 
already noticed as poisonous when retained in the system, and which 
are therefore expelled from it, or at least from the nourishing fluid. 
Holding these substances in solution, it is carried on with the current 
of the blood to the other great excretory organs, the skin and the 
kidneys, whence it passes out of the system, carrying with it, through 
those organs, the substances which each is designed to eliminate, but 
which it cannot remove unless brought to it in solution. 

The entrance of the water may be opposed as it were, in limine, 
by obstruction high up in the intestinal canal ; or, again, its passage 
into the circulation may be intercepted in the portal system, or by 
disease in the liver or, even, further on, in the heart and lungs ; all 
which obstructions may be so great as to prevent there being such a 



36 FOREIGN INGREDIENTS. 

supply of redundant water in the blood as is required for the solu- 
tion of the excretory matters, and from this cause there may arise 
inquination of the blood by those substances. 

Besides the above substances, which are continually formed in the 
course of circulation, and which are as continually removed by the 
deputary organs, others, foreign to the blood in a healthy state, may 
be present in it in disease ; thus we know that the blood in health 
has an alkaline reaction: in some forms of disease, as stated by 
Yogal, the blood is neutral, or at times even acid. This depends 
probably upon the presence of free lactic acid, and occurs in diseased 
conditions in which a tendency to decomposition in the blood may 
be suspected. 

Sugar, again, is a substance foreign to healthy blood; but in dia- 
betes (in which disease there is probably a defect in that action of 
the liver by which the sugar formed in the stomach is rendered 
susceptible of the normal changes in the lungs) it is present in the 
general circulation, from which it is carried off by the kidneys, not 
however before the blood had become so far impregnated with it as 
to allow of its detection by a chemical analysis. 

Pus in the blood is not a very rare occurrence in several morbid 
conditions of the system to be noticed hereafter. In some cases it is 
formed within the vessels, more frequently the veins ; in others it 
enters from without. 

Having now given a brief statement of the changes to which the 
blood considered, by itself, is liable, we proceed to speak of the 
derangements of the blood in circulation. 

The conditions of general plethora and general hyperemia con- 
stitute in themselves determinate diseases, which may become objects 
of special treatment, and will be best considered hereafter. Local 
plethora, however, or, as it is more commonly termed congestion, or 
hyperemia according to the French authors, besides that it is in 
itself not unfrequently an immediate object of treatment, occurs, 
either as cause or effect, in the greater number of diseases of which 
the living body is susceptible. It is true, indeed, that many organs 
and vessels admit of a considerable range in the quantity of blood 
circulating through them in a state of health, this variation depend- 
ing upon the varying activity of the organ ; but it is equally true 
that, when long-sustained or excessive in quantity, these accumula- 
tions give rise directly to derangement of function, and often consti- 
tute the first step towards structural changes. 

The consideration of the subject of congestion is essential to the 
right understanding of those important affections, inflammation, 
dropsy, and haemorrhage. Congestion or hyperemia may arise, 
1, from the increase of the flow of blood to the part; 2, from 
an increase of the capacity of the part for blood ; and, 3, from a 
diminished flow of blood from the part. 

(1.) The first of these constitutes the active congestion of most 
authors, and the active or sthenic hyperemia of Andral, sometimes 



CONGESTION. 87 

called also engorgement. It is not inflammation, neither does it 
necessarily lead to it, though it bears a most important relation to 
that complex process, since, when the latter does occur, active or 
sthenic hyperemia is the first step that leads to it. 

In order to the right understanding of the nature of congestion, 
and also of the right application of the means for its removal, it is 
necessary to bear in mind that an increase in the quantity of blood 
sent to a part is not necessarily dependent upon, or even always as- 
sociated with, an increased quantity in the system at large, or even 
upon an increase of the injecting force of the heart. 

To explain this we may recur to some physiological considerations 
respecting the moving powers of the circulation. The first propel- 
ling power of either circulation is the systole of the ventricle, by 
which the artery is filled and its elasticity overcome. As soon, 
however, as the systole is completed, the sigmoid valves being closed, 
the pressure which the large arteries exert upon the blood by their 
contractility can act only in propelling it in a continuous current, so 
that we may regard the large arteries and sigmoid valves as an ap- 
paratus for converting an intermitting motion into a continuous one, 
such as the fly-wheel of a steam engine : or, to use the more appro- 
priate comparison of Sir Charles Bell, the elasticity of the artery acts 
like the compressed air in a fire-engine to produce a continuous 
current from a force acting at intervals. 

It has been shown that, in addition to its yellow elastic tissue, the 
middle fibrous coat of the arteries contains nonstriated muscular 
fibre, giving to it a degree of real muscular contractility in addition 
to the mere physical property of elasticity; yet there is no reason 
for concluding that these fibres produce any peristaltic movement 
which would exert a propelling force upon the contents of the ves- 
sels, though they probably have the power of regulating the calibre 
of the artery, for purposes to be hereafter explained. 

The movement of the blood in the capillaries, however, appears to 
be greatly assisted by a different power, viz., an attractive force, 
arising from the mutual affinity of the blood in the capillaries, and 
the tissues surrounding those vessels. 

In a word, the systole of the ventricle, acting mediately through 
the elasticity of the arteries, is the propelling force by which the 
blood is conveyed through the arteries to supply the capillary vessels, 
whereas the circulation in the latter is maintained by the same force, 
aided by the mutual interaction of the blood and the surrounding 
tissues. 

It is a physiological fact scarcely needing demonstration, that 
various stimuli, whether — mechanical, as rubbing, or scratching, or 
the agency of the imponderables, as heat and electricity, or — chemical, 
as mustard, cantharides, ammonia, &c, or — vital, as the special stimulus 
of any particular organ, for instance, the application of any excretory 
matters to the kidneys by the blood, or the presence of an impreg- 
nated ovum in the uterus, increase the flow of blood through that 
part, antecedently to any increase in the force or frequency of the 
pulsations of the heart, and therefore independently of it; and 



38 CONGESTION". 

further, that when this hyperemia is long maintained, there ensues 
an enlargement in the artery supplying the part, unattended with 
any corresponding enlargement of the other arteries of the body, 
and therefore not to be accounted for by a general cause, such as 
increase in the injecting force of the heart, which must alike affect 
all the arteries of the system. This connexion between the activity 
of the circulation in a particular part, and the diameter of the artery 
supplying that part, is probably maintained by the branches of the 
sympathetic nerve so freely distributed along the arteries acting 
upon the muscular fibre before mentioned, (p. 44.) 

This increase of the calibre of the arteries may be propagated still 
further backwards along the course of those vessels, so as eventually 
to influence the general circulation, and through it the action of the 
heart itself. 

Before proceeding further, it may be well to state briefly the phe- 
nomena which are observed in the progress of local congestion, as 
well those which from their minuteness can be seen only in the 
transparent parts of animals by the aid of the microscope, as those 
which are appreciable by the unassisted senses, and may be observed 
in all the tissues when irritation has been applied to any tissue, as in 
pricking the web of a frog's foot under the microscope, or the ap- 
plication of alcohol to a membrane : after a time varying from a few 
minutes to some -hours, a change in the condition of the small blood 
vessels is observed; they become enlarged and distended,* the blood 
also passing through them with increased velocity ; at the same time 
that new vessels appear to be produced, most probably from those 
which before did not allow of the passage of the red corpuscles, or 
which admitted them in a quantity insufficient to render their colour 
apparent, now permitting them to enter them freely; the globules 
also manifest a tendency to cohere into irregular masses, which some- 
times pass through the capillaries, and may be observed in the veins. 
This is active congestion, or the sthenic hyperemia of Andral. 

This state of things cannot, however, continue long without leading 
to further change ; if it have not been intense, the increased quantity 
of blood and rapidity of its movement may gradually subside, and 
the vessels return to their original condition, or it may pass into in- 
flammation, to be described hereafter, or it may be relieved by effu- 
sion of the whole blood, giving rise to haemorrhage, or of the liquor 
sanguinis, as in fibrinous dropsy, or of serum, as in serous dropsy, or 
it may pass into the next form of congestion. 

(2.) This form of congestion is spoken of by authors in this country 
under the name of passive congestion, and by Andral and the French 
pathologists as asthenic, or passive hyperemia, in which the capillaries 
become distended with blood, and the motion of that fluid impeded. 
Passive congestion may also occur without any previous acceleration 
of blood in the arteries or capillaries, of which we may often see 
instances when the lower or depending parts of aged or debilitated 
subjects become livid or purplish, owing to the contractility of the 

* Alison's Pathology, p. 99. 



CONGESTION. 39 

capillaries not "being sufficient, as in health, to overcome the dis- 
tending force arising from the gravitation of the blood. It also suc- 
ceeds to active congestion, the increased energy of contractility in 
the small vessels being followed by a corresponding deficiency, so 
that, becoming dilated under the force of the active congestion, they 
have not sufficient contractility to resume their original size, but 
remain permanently distended with blood. 

(3.) Allusion has been made to impediments in the course of the 
circulation causing accumulation of the blood which is following the 
obstructed portion, or, as it is termed, tergal to it. This form of 
congestion, which is termed mechanical, exists exclusively in the 
first instance in the veins, though it may be propagated from them 
to the capillaries : — it is instanced by the effects of compression upon 
the venous trunks of an extremity ; — by obstruction to the passage 
of the blood through the right side of the heart, which gives rise to 
venous congestion of the whole system, by opposing the return of 
the blood through the ascending and descending cava ; though this 
congestion, however, affects chiefly the parts nearest to the heart; — 
and by disease of the liver obstructing the passage of the blood 
through the portal system, and inducing congestion in the capillaries 
of all those parts, from which the blood is conveyed by the veins 
converging to form the vena portas. 

Although many of the phenomena which have been described as 
constituting the state of congestion, can only be observed in the 
superficial textures of the body, yet we have reason, not only from 
the considerations already adduced, but from the evidence afforded 
by inspection after death, for knowing that the internal organs are 
equally liable to the different forms of congestion. The part thus 
affected is to the eye redder than natural ; this redness is observed 
under the microscope not to be general, but to follow the course of 
the capillaries, the interstices remaining colourless ; when the part is 
cut into a more than ordinary quantity of blood flows from it, the 
corpuscles in which have undergone little or no alteration. The 
affected part is also denser than usual, but the consistence is normal. 
A sudden or intense congestion of blood may in some instances prove 
immediately fatal, as when it occurs in the brain, or in congestive 
fever; though this is, comparatively, a rare occurrence. 

In the treatment of congestion or hyperemia, it is necessary to 
bear in mind the different forms which it assumes, and the excess or 
defect of the vital affinities upon which it depends. This is more 
especially true of the two first forms, which result from very different 
or even opposite conditions, but which, nevertheless, as has been just 
observed, merge into each other by almost insensible degrees; so 
that when either of these conditions exists singly, the most applica- 
ble treatment is, in the case of the second, almost opposite to what it 
would be in the first. Of this we have a ready illustration in the 
case of the eye, the transparency of whose textures allows us to see 
the variations in the fulness of their vessels. Thus, after the applica- 
tion of cold, or any irritating cause, the vessels of the conjunctiva, 
which in health do not admit the red corpuscles, may be seen travers- 



40 CONGESTION". 

ing that membrane in all directions, and carrying red blood; and 
we know that at first this condition is best relieved by remedies 
which depress vascular action, and is aggravated by the application 
of any stimulant. "We also know that, when this congestion has 
passed into its second or passive state, a change may be often de- 
tected in the vessels, which appear in a more distended state than at 
first, having lost their vivid colour and assumed a dusky hue ; and 
then, stimulating or almost irritating applications will often speedily 
restore the natural paleness of the part, by re-exciting the contrac- 
tility of the capillaries. 

We cannot, indeed, actually see the same thing going on in in- 
ternal parts, and, although inspection after death may give evidence 
of the existence of congestion, it gives us none as to its stage or 
character ; an instance, if any Avere required, that morbid anatomy 
is a part only of pathology. It furnishes us, indeed, with much 
knowledge respecting the changes produced by disease, but it is not 
conversant with disease itself; that is, with the deranged action 
upon which disease depends, and of which structural changes are 
the effects, and not the causes. We may, however, by comparing 
the revelations of morbid anatomy with the symptoms observed during 
life, and by again correcting the deductions thus obtained by the 
known effects of remedies, arrive at pretty certain conclusions as to 
the existence of one or other of these forms of congestion in internal 
organs. Of the importance of the distinction thus observed, we shall 
presently have a remarkable instance in the bronchial membrane. 

The details of the particular mode of treatment best adapted to 
each form of congestion will be most conveniently considered when 
we come to speak of special diseases; there are, however, a few 
general principles, which will be best appreciated when regarding 
congestion simply as such, without embarrassing ourselves with the 
more complex phenomena with which it is commonly associated. 

The most obvious means of relieving any congestion would, at 
first sight, appear to be the abstraction of blood from the system, 
which, by diminishing the whole volume of the circulating fluid, 
might be expected to lessen, in the same proportion, the quantity 
supplied to each particular organ. Experience, however, has not 
shown this to be the case : since not only are those apparently the 
most ex-sanguine equally liable with others to local congestions, or 
even more so, but also, in many instances, where a congestion has 
been established, it would appear as if the system might almost be 
drained of its blood, and yet, the portion which remains, as if obedient 
to the local stimulus, will still rush in a redundant quantity to that 
part. One reason of this may be that, by abstracting blood from a 
vein, or a branch of an artery, we diminish, though only for a time, 
the volume of the blood in the larger vessels, and at the same time 
depress the action of the heart, without materially affecting the move- 
ment of the blood in the capillaries, which, as we have already seen, 
though not independent of the former, is yet greatly influenced by 
forces affecting wholly the capillary system. The influence of blood- 
letting is, perhaps, fairly stated by Andral, in the following words : 



CONGESTION. 41 

'•By the employment of bloodletting, the organ congested is relieved 
of a part of its superabundant fluid; the general mass of blood in 
circulation is diminished; and a powerful cause of irritation thus 
withdrawn from the system ; but neither by local nor general bleed- 
ings can we remove the unknown cause, under the influence of which 
the hyperemia was originally developed. If, however, this cause be 
not particularly active or violent in its operation, its influence may be 
considerably diminished, or even completely paralyzed by sanguine- 
ous abstraction, as the blood is thus withdrawn from the seat of irri- 
tation as often as it tends to accumulate there, and the hyperemia is 
thus prevented from establishing itself in the part : but if the exciting 
cause of the congestion be more violent in its action, we shall in vain 
attempt to remove it by bloodletting It is, therefore, the ex- 
citing cause which we should endeavour to investigate and coun- 
teract, and not exclusively confine our attention to the local conges- 
tion, which is merely an effect ; an elementary part of a very complex 
phenomenon." According to the above view, which is, to say the 
least, not too unfavourable to the use of bloodletting, it is not merely 
the consideration of whether the congestion be active or passive that 
is to guide us in the use of that remedy, as even, in the case of the 
former, it may aggravate the mischief, since a local hyperemia, in an 
anaemic state of the system is a greater evil than where there is a 
normal condition of the general circulation. That a local congestion 
may be accompanied by increased action of the heart and large 
vessels, and may even excite such increased action, has been already 
explained, and it is evident that the effect must be to maintain, or 
even to aggravate congestion; and it is under these circumstances 
that benefit may be expected from the general abstraction of blood. 
It is then by the force of the heart's action that we are mainly to be 
guided, such force being measured, not so much by the impulse 
which seems to be given to the blood in the artery, as by the power 
with which it resists the pressure of the fingers. Even these indica- 
tions, however, must be received with the greatest caution, if not 
altogether disregarded, in cases of congestion arising in the course 
of exanthems, or other diseases of the general system excited by 
morbid poisons. 

Local depletion, when it can be applied, presents a better prospect 
of relieving local congestion, since by it we may hope to unload 
directly the distended capillaries, and this too by the abstraction of a 
quantity of blood far less than could be expected to produce any 
relief by general bleeding. It unfortunately happens that, in the 
greater number of cases, we cannot remove blood directly from the 
part affected; when, for instance, we suspect an internal congestion 
we may indeed have recourse to leeching or cupping over its proba- 
ble seat, by which means we may relieve neighbouring vessels ; but 
these are often supplied by different arteries from those distributed 
to the part affected, and, consequently, we cannot expect the same 
result as would be produced by emptying the gorged capillaries of 
the part. Still we have reason to believe from experience that we 
may, even in this way, check or control the disease. Though the 



42 TREATMENT — BLEEDING, SEDATIVES. 

mode by which this result is produced is not very easily explained, 
much indeed may be the revulsive action of the leeches or cupping- 
glasses, especially of the latter, though this is hardly sufficient to 
account for the effects produced. 

General bleeding, then, is applicable in active congestion when 
there is considerable increase in the force and frequency of the 
heart's action, as indicated by the arterial pulse, this being generally 
the condition when such congestion is merging; into inflammation. 
Local depletion, from a part near the seat of the congestion, is bene- 
ficial when we have reason for believing that the congestion is of an 
active character, although there be no great increase of the heart's 
action. It must, however, here be urged that regard should be had 
to the general condition of the system before venturing upon this 
less powerful mode of depletion ; for it must be borne in mind that 
by the means ordinarily employed blood is removed from the smaller 
arteries and veins as well as from the capillaries, and therefore that 
the effects of the depletion are not solely confined to the latter vessels, 
but in some states of the system they show themselves strongly upon 
the action of the heart and large vessels. The advantage of the truly 
local bleeding, that is, of relieving directly the capillaries of the part 
affected, where it can be done, as when the congestion is situated on 
the surface, applies to the passive equally with the active form ; since 
the blood thus removed flows almost entirely from the distended 
capillaries, where it was in a state of stasis, entirely removed from 
the pale of the general circulation, and, therefore, unlikely, by its 
abstraction, to produce any depressing effect upon its moving powers. 

There are various medicines and applications which are reckoned 
as sedatives to the circulation; of these the former are chiefly of 
the nauseating kind, as tartar-emetic, digitalis, and colchicum; and 
although it is doubted by many whether this sedative agency can be 
exerted unless nausea be also induced, that they do exert such an 
agency is certain, though they do not appear to act each on the same 
class of vessels. Of the agency of colchicum we know but little, 
though its sedative effect seems to be produced mainly through the 
heart and large vessels. Digitalis, again, is undoubtedly a sedative 
to the heart. The tartarised antimony, on the other hand, though it 
unquestionably exercises some depressing influence on the heart, has 
certainly as great, if not greater, influence upon the capillaries, and is 
therefore one of the most efficient means we possess of combating 
active hyperemia. 

A very important means of producing a sedative effect on the 
whole system, including the capillaries, and therefore advantageous, 
or rather essential, in the treatment of active congestion, is what is 
termed the antiphlogistic regimen, by which is meant low diet, the 
avoidance of muscular exertion and mental emotion. The external 
application of cold, as by effusion, or by its more continued local 
application, is a powerful sedative, and sometimes very useful, though 
unless it be carried beyond the limits consistent with perfect safety, 
its effects are but transient : applied locally for any considerable time, 
as when cold applications are used to erysipelas of the scalp, it is apt 



MECHANICAL CONGESTION. 43 

to set up secondary hyperemia, often more dangerous than the pri- 
mary disease. 

It has been already observed that, when a hyperemia or conges- 
tion has passed into the asthenic or passive state, the depressing or 
sedative remedies are productive of harm rather than benefit, whereas 
stimulant, tonic, or astringent remedies become serviceable. The indi- 
cations which the latter remedies are here calculated to fulfil are, 1, 
to excite the action of the heart and large vessels, and thereby 
increase the vis a tergo, by which, the blood is to be removed from 
the distended capillaries; 2, to enable the latter vessels to relieve 
themselves by increasing their contractility ; and, 3, it may be that, 
by acting upon the nervous system, and through the organic nerves, 
they increase the vital activity, upon which depends the interaction 
between the tissues and the blood in the capillaries. 

The most direct stimulants to the action of the heart are alcohol 
and gether taken into the system, and their judicious employment is 
often followed by the best results in passive congestion. It must be 
remembered, however, that their action is not only transient but apt 
to be followed by a corresponding depression ; this may be in some 
measure counteracted by administering them in small doses fre- 
quently repeated. Ammonia probably acts more upon the nervous 
system than immediately upon the heart ; it has, however, a secondary 
and stimulating influence upon the organs of circulation. The effect 
of internal medicine in directly increasing the contractility of the 
extreme or capillary arteries may perhaps be doubted, though when 
a passive congestion is within reach, astringent and stimulating sub- 
stances locally applied restore the tonicity of these vessels. The 
benefit moreover of a tonic regimen, aided by medicines of the same 
character, as cinchona, quinine, and the other vegetable tonics, or 
(when the state of the system seems to call for it) by mineral tonics, 
as iron or zinc, cannot be doubted. 

The third form of congestion depending mainly upon mechanical 
obstructions to the return of the blood through the veins, must be 
combated mainly by endeavoring to remove these obstructions, or, 
when this cannot be effected, by regulating the circulation so as to 
adjust it as nearly as possible to the altered condition of the system. 
Local depletion may sometimes be called in to aid in fulfilling this 
latter indication, and it may even become necessary to abstract blood 
generally, though this latter must be regarded only as a measure 
adapted to a passing emergency, since congestion of this character is, 
in the greater number of instances, mainly dependent upon a defect 
in the moving powers of the circulation, and therefore the probability 
of its recurrence is increased by whatever tends to lessen the force of 
the heart's action. 



4A INFLAMMATION. 



IV. 

INFLAMMATION". 

Having now briefly considered the more simple dynamical or 
functional derangements of the solids, as well as of the blood, we pro- 
ceed to that more complex, and most important affection — Inflamma- 
tion, — a process into which enter nearly all the elementary morbid 
changes which we have been considering, since we have — changes in 
the irritability and in the contractility of the vessels of the part, — 
changes in the blood and in its attraction for the tissues, — changes in 
the nervous force, and — changes in the nutrition of the part. 

The word inflammation, derived from inflammo, I burn, was pro- 
bably suggested in the first instance from fanciful and erroneous 
notions respecting the disorder which it was used to denote. The 
word is however now retained as a conventional term, used, without 
reference to its literal and original meaning, to express a certain pro- 
cess, or series of phenomena, about which medical men are in the main 
agreed; and so used it is preferable to many words by which it has 
been proposed to replace it, since it is not easy to disentangle such 
words from the theories upon which they have been founded, and 
which may eventually prove to be erroneous. 

Pain, swelling, heat, and redness, have been from the earliest ages 
of medicine recognised as the indications of inflammation in any part 
in which they are combined. These conditions are not, however, all 
of them invariably present in any great degree, thus the degree of 
pain will vary much according to the structure and sensitiveness of 
the part affected. It is much less in inflammations of the mucous 
membranes, and of the parenchymata of the several viscera than in 
those of denser structures, as the serous membranes ; or of parts more 
abundantly supplied with nerves of common sensation, as the skin. 
The swelling and redness vary according to the texture of the part 
and intensity of the inflammation. The heat, again, belongs almost 
entirely to the commencement of the inflammation, and is most mani- 
fest in those parts which are the furthest from the centre of the 
circulation, and of which the ordinary temperature is consequently 
the lowest; since, in the most intense inflammations, the heat seldom 
rises above the healthy standard of the blood at the heart. 

In order to complete the description of inflammation, we must add 
to the pain, swelling, heat, and redness, a tendency to the effusion 
from the blood-vessels of fresh matter, generally liquor sanguinis, 
speedily assuming the form of coagulated lymph, or pus. It is true, 
indeed, that these consequences may sometimes not ensue, owing to 
the slight degree or short duration of the inflammation. Still we 
may fairly argue, from precisely similar instances, that they would 
have done so but for the above circumstances. "A peculiar perver- 
sion of nutrition or secretion," to use the words of Dr. Alison, "we 



\ 

DESCRIPTION OF INFLAMMATION, 45 

may hold to be essential to the very existence of inflammation ;" and 
in this, it may be observed, consists the difference between inflamma- 
tion and active congestion ; the latter, indeed, may be induced by 
stimuli external to the vessels, but the phenomena of congestion, as 
such, are confined to the vessels ; whereas inflammation, being extra- 
vascular, and implying a perversion of nutrition, implies also a dis- 
turbance in all the tissues concerned in nutrition. Now, as is observed 
by Professor Paget,* " The conditions of the healthy maintenance of 
any part by nutrition, are, 1, a regular and not far distant supply of 
blood ; 2, a right state and composition of that blood ; 3, (at least in 
most cases,) a certain influence of the nervous force ; and, 4, a normal 
state of the part in which nutrition is to be effected. All these are 
usually altered in inflammation." It is not therefore to the blood and 
blood-vessels alone that we are to look for an explanation of the phe- 
nomena of inflammation. 

In the first commencement of inflammation, as observed imme- 
diately after the application of a stimulus capable of exciting it, the 
minute vessels of the part become contracted, and the movement of 
the blood in them is quickened, according to many authors, though 
very accurate observers, and amongst them Professor Paget, maintain, 
and probably with truth, that there is no quickening, but rather a 
retardation of the flow of blood simultaneously with the contraction. 
After a time, however, an opposite condition of the capillaries may 
be observed, they become distended and dilated, and the movement 
of the blood in the focus of the inflammation is retarded, and in some 
capillaries it stops entirely, whilst around this focus the blood runs 
quickly in tortuous and distended vessels, and still further off it runs, 
still quickly, but through less distended vessels. 

Over the whole surface of the inflamed part, a number of small 
vessels become apparent, which could not be seen before ; this is, no 
doubt, owing to capillaries allowing the passage of the red corpus- 
cles, which could before admit only the liquor sanguinis, or colourless 
liquid of the blood. Besides being enlarged, the blood-vessels are 
otherwise changed in shape; they are elongated, and consequently 
rendered more tortuous, and they also, as stated by Professor Paget, 
from observations by Kolliker and Hasse, have a tendency to become 
aneurismal or varicose. The movement of the blood is further affected 
by the arrangement of the red corpuscles, which cohere into irregu- 
lar masses, distending the blood-vessels, which often appear regularly 
crammed with them, "and often," says Professor Paget, "when there 
is stagnation in a considerable artery, one may see the blood above or 
behind it pulsating with every action of the heart, driven up to the 
seat of stagnation, and thence carried off by the collateral branches ; 
while in the corresponding vein it may oscillate less regularly, delay- 
ing till an accumulated force propels it forward, and as it were, flushes 
the channel." 

It is to be observed that the increased calibre of the vessels and 
the accelerated flow of blood through those around the part where 

* Lectures on Inflammation. 



46 BLOOD IN INFLAMMATION. 

the inflammation is the greatest, appear to do more than compensate 
for the retardation and stagnation at the central parts of the inflam- 
mation, so that the quantity of blood circulating through an inflamed 
part exceeds the quantity in health, for it has been ascertained that 
the blood returned by the veins from an inflamed limb, is at least 
three times as much as that returned by the corresponding veins on 
the opposite side. 

Thus far the changes which have been described in the blood- 
vessels coincide pretty closely with those which have been pointed 
out as occurring in congestion ; but congestion and inflammation are 
not therefore to be confounded. Congestion is in many instances a 
strictly natural and healthy process — the affl ux of blood in obedience 
to natural and healthy stimuli, to a part where an increased supply is 
wanted for physiological purposes. Of this we see instances in the 
impregnated uterus, and in the increased vascularity of the tissue 
whence the horns are nourished, when they are reproduced after 
having been shed. Congestion, indeed, almost always accompanies 
inflammation, but it is rather to be considered as a consequence of 
that excitement or irritation whereby the inflammation is set up, than 
as itself forming the first stage of the inflammation. 

Whilst the above changes are taking place in the capillaries, and the 
surrounding textures, which are the seat of the inflammation, the 
blood in the vessels of the part likewise undergoes alteration. This 
alteration includes not only changes in its chemical and physical, but 
also in its vital properties, by which latter is meant its adaption to 
the nourishment of the tissues to which it is distributed. 

We have before spoken of the tendency sometimes manifested by 
the red corpuscles, to arrange themselves in rows like rouleaus of 
coin ; this tendency, which was first distinctly pointed out by Mr. 
Wharton Jones, and which is so efficient a cause of the buffy coat, is 
one of the changes which take place in the blood in inflammation. 
Much of their colouring matter has also been observed to escape from 
them, diffusing itself through the liquor sanguinis, and giving to the 
blood the appearance of a uniform red mass, interspersed throughout 
with colorless globules. These globules have been by some supposed 
to be the nuclei of those red corpuscles from the investing mem- 
branes of which coloring matter has escaped ; an opinion which is 
at variance with the views now entertained respecting the structure 
of the corpuscles. It is more probable, therefore, that the corpuscles 
alluded to, are the white or rudimental corpuscles of the blood. The 
red corpuscles are, throughout the system, diminished in inflamed 
blood, though they may be present in an increased proportion at the 
seat of the inflammation. The fibrine and white corpuscles are in 
excess in inflamed blood, though from the difficulty of separating 
these two principles, it is by no means certain whether this excess is 
to be attributed chiefly to one or the other. It is probable, however, 
that when the inflammation occurs in healthy subjects, the increase 
takes place almost entirely in the fibrine, but that, in debilitated 
subjects, it is due mainly to the corpuscles. Andral states that in 
strong subjects the proportion of fibrine during inflammation may 



NERVES IN INFLAMMATION. 47 

reach as high as from five to seven or even eight per thousand 
of the whole blood. 

Besides the increase in its quantity, the fibrine of the blood under- 
goes a no less remarkable change in its power of fibrilation or coagu- 
lation, a circumstance which materially facilitates the formation of 
the buffy coat in inflamed blood. It has already been shown (p. 41) 
that the slower coagulation of the blood, the more rapid subsidence 
of the red corpuscles, and increased proportion of the fibrine (all 
which conditions are present in a greater or less degree), promote 
the formation of the buffy coat ; but that there is some other cause, 
tending to produce it, is evident from the facts, that the separation of 
the liquor sanguinis from the red corpuscles may often be observed in 
inflamed blood before the time that coagulation would have com- 
menced in the healty state ; and that this separation may take place 
in films of blood so thin as not to allow of a stratum of liquor san- 
guinis being laid above one of red corpuscles. 

The conditions which concur for producing the buffed and cupped 
clot of inflammation, appear on the whole to be as follows — relative 
diminution in the number of red corpuscles, and proportionate 
increase in the quantity of fibrine or white corpuscles : — more rapid 
and closer aggregation of the red corpuscles into rolls, and of these 
again into masses having large intervening spaces filled with liquor 
sanguinis. To the above may be added a continued slow coagulation 
of the fibrine, after the separation of the clot ; the effect of which is, 
that the upper layer of the clot being disengaged from the red 
corpuscles its edges are drawn towards each other, and thus is 
given to the surface that concave form which is commonly called 
"cupped." 

Two other changes of the blood in inflammation — the diminution 
of red corpuscles, and increase of water ; which, as we have already 
seen, favor also the formation of the buffy coat ; although they are 
but little adapted to explain " any of the phenomena of the local 
process," nevertheless furnish us with a resemblance between the 
condition of the blood in inflammation, and in several states of the 
system which are commonly believed to be the most opposed to it ; 
but in which the accurate clinical observer is well aware that it 
frequently arises — viz., spontaneous anaemia and that state of the 
system which is induced towards the close of many protracted dis- 
eases. 

It is very true, as is observed by Professor Paget, that none of the 
conditions, the existence of which has been ascertained, either by 
chemistry or by microscopical observation, are sufficient to explain 
the local phenomena upon any known principles. But as it is 
known that many instances occur, in which inflammations have 
their origin in a morbid condition of the blood, we are compelled to 
believe that such morbid condition may exist, though it elude both 
chemical and microscopical observation, and must, in the present 
state of our knowledge, be described as a loss of adaptation to the 
purposes of nourishment, and, consequently, of the mutual affinity 
between the blood in the capillaries and the surrounding tissues. 



48 CONSEQUENCES OF INFLAMMATION. 

Of the condition of the nerves during inflammation nothing can 
be known by actual demonstration. That disturbance of the nervous 
influence may of itself excite inflammation, we know from the effect 
upon the tissues of the eye produced by disease or injury of the 
fifth nerve, and also from the kind of sympathetic inflammation 
which is communicated through the nerves of an inflamed part to 
those of another part. That irritation applied to the sentient extre- 
mities of the nerves will produce a certain degree of inflammation, 
is apparent from the eruption upon the surface produced by electric 
sparks. 

The pain felt in an inflamed part also suggests the idea that the 
nerves of that part are in what is termed a highly " excited" state, 
and of this there is further evidence in the extreme tenderness and 
susceptibility to every stimulus. That pain, and that very intense, 
may often exist without inflammation we know ; still it is not to be 
overlooked, that in very severe paroxysms of pain, as in facial 
neuralgia, there arises an inflammatory oedema and redness of the 
part. 

It may, perhaps, be too much to assert that disturbance of the 
nervous system is as much an essential part of inflammation as is 
that of the vascular system; yet we have seen that congestion or 
excitement of the vascular system may exist without inflammation, 
as well as pain or excitement of the nervous system. We know 
also that congestion, long continued, is apt to result in inflammation, 
and so also is long continued pain or excitement of the nervous 
system; and if it be said that inflammation may exist in parts 
which are scantily if at all supplied with nerves, so also, it may 
be answered, will it arise, as in the cornea, in parts which have no 
vessels. 

That inflammation may be induced, by an altered condition of the 
part, independently both of the blood-vessels and nerves, is apparent 
from the instance just cited of the cornea, which has neither ; and 
as regards the increased afflux of blood to an inflamed part, we will 
again repeat what has been before insisted upon, viz., that it is the 
condition of the part which determines the supply of blood rather 
than the supply of blood the condition of the part. 

It is not therefore to be inferred that inflammation may not arise 
from disturbance either in the blood-vessels, the blood, the nerves, 
or in the proper elements of the part itself, but that the state com- 
monly recognised as inflammation cannot be fully established without 
involving them all ; and as it may begin in any one of these disturb- 
ances, so is it impossible to ascribe to either the precedence in the 
order of sequence, and therefore they should be studied as contem- 
poraneous events, rather than as following each other in any neces- 
sary series. 

The local changes now described are followed by certain conse- 
quences which have been treated of by many authors as the termi- 
nations of inflammation ; thus we read of inflammation terminating 
by resolution, by effusion, by adhesion, by suppuration, by ulcera- 



METASTASIS. 49 

tion, and by gangrene : strictly speaking, however, the first and last, 
viz., resolution and gangrene, are the only true terminations, since 
the different effusions may take place at any period of inflammation, 
and are not necessarily attended by its subsidence, although the 
term abscess, applied to a circumscribed suppuration, from abcedo, 
would seem to imply the notion of a departure of the inflammation. 

Resolution, which is in reality a subsidence of the inflammation, 
takes place when the state which we have just been describing 
passes away without leaving any permanent change in the part 
which was the seat of the inflammation. This subsidence takes 
place by just the same steps as those by which the inflammation had 
been established, but in an inverted order. The swelling diminishes, 
the rapid motion of the blood in the vessels surrounding the seat of 
the inflammation abates, whilst, at the focus of the inflammation, 
where stagnation had been established, the agglomerated corpuscles 
may be seen to separate and pass off in different channels, and the 
blood resumes its motion; the vessels gradually return to their 
former calibre, and recover their contractility, the redness and heat 
of the part disappear, and it is at length restored to its former con- 
dition. 

This termination is the most favorable result that can ensue in 
inflammation, provided it be not followed by diseased action else- 
where. Sometimes, however, inflammation undergoes resolution, 
and that very rapidly, in one part, to be set up again as rapidly in 
another, continuous with that in which it commenced. This disposi- 
tion to a continuous transference of inflammation by which it 
appears to creep along from one part of the same membrane to 
another, is more frequent in some textures than in others, as in the 
skin and the mucous membrane of the bronchi, and also in some 
varieties of inflammation than in others. 

It happens also, not unfrequently, that the inflammation suddenly 
subsides in one part and reappears immediately, and with the same 
intensity, in others remote from it, though generally in a structure 
similar to that which it has left. This sudden removal of inflamma- 
tion from one part to another is particularly liable to recur in acute 
rheumatism and some other inflammations of a specific character, 
and it is termed metastasis. 

This transference of inflammation from one part to another is a 
circumstance of which we often avail ourselves, and endeavor to 
imitate "by setting up an inflammation on an external part in the 
hope of withdrawing or subduing a more serious and dangerous one 
within. This mode of treatment is called counter-irritation ; the 
terms derivation and revulsion are also used to express it. It is not 
improbable that the subsidence of an inflammation after what have 
been called critical discharges or evacuations, are instances of fortunate 
or beneficial metastasis, as they proceed from a congestion connected 
either in the way of cause or effect, with the subsidence of the primary 
inflammation. When, however, resolution does not take place, the 
characteristic effusions of inflammation begin to make their appear- 
ance as soon as it is at its height. 



50 EFFUSIONS OF INFLAMMATION. 

The first of these products or effusions is the so-called serous 
effusion, from its apparent similarity to the serum of blood. When 
the inflammation is at its height a colorless liquid exudes from the 
capillaries, either infiltrating the surrounding tissues, or if the seat 
of inflammation be a secreting surface, increasing the secretion of 
the part. When, for instance, the inflammation is in the areolar 
tissue, we have from this cause a great increase of the swelling, and 
if it be a closed cavity we have dropsy of that cavity. It however 
rarely happens that this is the true serum of blood ; it is, in fact, as 
was long ago pointed out by Dr. Babington, in the paper already 
alluded to, liquor sanguinis, or blood deprived of its red corpuscles. 
This effusion has been described by Paget, under the term fibrinous 
dropsy, and differs from the true serous dropsy in that it contains 
fibrine, and is capable of coagulating after it is removed from the 
body. Another form of liquid effusion is pointed out by Professor 
Paget as happening from serous inflammatory matter capable of 
organization into cells. 

The fluid containing fibrine has generally the appearance of 
serum, from the circumstance of its retaining its fluidity, which it 
will do for a considerable time within the body, and that too after 
death. The reason of this delay in the coagulation is by no means 
obvious, though it is a propitious event ; for so long as the effusion 
is liquid, absorption may ensue on the subsidence of the inflamma- 
tion.* 

It may sometimes happen that serum is effused in inflammation, 
but this is only in the lowest forms, and the serum is very rich in 
water ; but, as a general rule, it is exceedingly rare as an inflamma- 
tory product. 

The same may be also said of blood, which, though it has been reck- 
oned among the effusions of inflammation, never occurs unless it be 
from the rupture, either of some of the highly congested capillaries, or 
of those delicate vessels which are formed in recently coagulated lymph. 
In the former case the haemorrhage is termed primary, and in the 
latter secondary; but in either it is to be regarded rather as an 
accident than as one of the natural results of inflammation. It not 
unfrequently happens that the coloring matter of the corpuscles is 
dissolved in the effused fluid, giving it the appearance of blood, 
which no doubt has led to the belief in the red corpuscles transuding 
through the walls of the vessels. * 

We have already seen that true serum rarely occurs as ^inflam- 
matory effusion, the characteristic product of inflammation being the 
blood-plasma, or as it is commonly termed, lymph, and which we 
will designate inflammatory lymph, to distinguish it from other sub- 
stances to which this term is applied. Of this inflammatory lymph 
the so-called serous effusions are merely modifications, and, like 
them, it occurs under two varieties, the fibrinous and the corpuscular. 

The fibrinous variety occurs when the liquor sanguinis, which is 
poured out as before stated, becomes of a thicker and more gelatinous 

* Paget, opus citat. 



EFFUSIONS OF INFLAMMATION. 51 

character, and at last assumes a form closely resembling, in appear- 
ance and composition, the buffy coat of the blood, — the adhesive 
inflammation of surgeons. 

This product of inflammation may be seen most plainly in the 
formation of adventitious deposits, which are frequently found upon 
serous membranes, sometimes gluing together their opposed surfaces, 
as the pleura pulmonalis and pleura costalis, or the free and attached 
surfaces of the pericardium, after an attack of inflammation of either 
of these membranes. The lymph is sometimes effused I with the 
serum, the latter remaining unabsorbed in the cavity, whilst the 
former adheres to its serous lining, or in cases of less active inflam- 
mation remains in loose shreds, which subside to the lower part. 
At other times the lymph or fibrine alone is effused, or, what is more 
probable, the serum is absorbed almost as fast as it is poured out, 
and the result is, the deposition of lymph alone upon the surface of 
the membrane, little or no serum remaining in the cavity. 

Now it being one of the properties of inflammation, of which no 
satisfactory explanation has as yet been given, to propagate itself 
from one surface to another in contact with it, especially when these 
surfaces are similar structures, the consequence must be, that since 
the opposite surfaces of serous membranes, when not separated by 
effusion, are always in contact with each other, the inflammation of 
one portion of such membrane, the pleura pulmonalis, for instance, 
must, in the absence of such fluid, give rise to inflammation of the 
corresponding part of the pleura costalis, and the lymph, poured 
forth by each, forms, as it were, a cement by which these parts are 
united, the union becoming firmer by its subsequent organization. A 
very similar process takes place in the inflammation of the areolar 
tissue of the body, of the spongy texture of the lungs, and other 
parenchymatous viscera, the lymph effused into the interstices as- 
suming the solid form, sometimes almost immediately, at others not 
till after a considerable time. In the former case the result is a 
hardening almost from the first, in the latter there is first a swelling 
or distension of the part, which pits under the pressure of the finger 
owing to the infiltration of the texture by the liquor sanguinis; 
afterwards, the serum being absorbed, the part becomes hardened by 
the coagulation of the lymph or fibrine. 

The exudation of lymph or fibrine does not very often happen 
upon the free surfaces of mucous membranes, though it does some- 
times occur when the inflammation is very intense, as in the case of 
the exudations in the larynx, trachea, and bronchi, in croup, and in 
patches in the larger intestines in dysentery. 

It also not uncommonly takes place in the areolar tissue beneath 
such membranes, giving rise to a thickening, that encroaches upon 
the tube which it lines, and causes a diminution of its calibre, as in 
stricture of the urethra. 

"In the corpuscular variety of lymph," says Professor Paget,* 
" no coagulation, in the ordinary sense of the word, takes place, but 

* Lectures on Inflammation. 



52 VAKIETIES OF INFLAMMATORY LYMPH. 

corpuscles form and float free in the liquid part. Typical examples 
of this form are found in the early-formed contents of the vesicles of 
herpes, eczema, and vaccinia, in the fluids of blisters raised in cach- 
ectic patients, in some instances of pneumonia, and in some forms 
of inflammation of serous membranes." These corpuscles, exudation 
corpuscles, or exudation cells, resemble, in their first appearance, the 
white corpuscles of the blood, though they admit of many varieties 
in their subsequent changes. 

These two varieties, namely, the fibrinous and the cellular, con- 
stitute the typical forms of inflammatory lymph, but it will very 
commonly happen that the effusion is of a compound character, the 
fibrine and the corpuscles being mixed in various proportions, and 
accordingly, as the former or the latter preponderates, will be the 
probability of the lymph being organized into tissue, or degenerating 
into pus, or some other inorganizable product; the probability, in 
short, of adhesive or suppurative inflammation. 

It becomes, therefore, a matter of great practical importance to 
ascertain what are the conditions upon which depend the effusion of 
one or the other form of lymph. 

It has generally been stated that this is determined mainly by the 
character of the tissue in which the inflammation is seated, and it is 
undoubtedly true that ceteris paribus, adhesive inflammation is more 
likely to take place in some tissues, and suppurative in others. 
Thus, in serous membranes the inflammatory lymph is commonly 
fibrinous, and, having a great tendency to form adhesions; whilst 
that effused in inflammations of mucous membranes, is prone to 
assume the form of pus. But it is also true that the same tissue, 
even when excited to inflammation by the same cause, may pour out 
either fibrinous or corpuscular lymph ; thus the fluid of the vesica- 
tion of a blister applied to a healthy subject, deposits shreds of 
fibrine, whereas, as we have already seen, the same fluid, in a cachectic 
subject, contains merely exudation corpuscles, and has no power of 
spontaneous coagulation ; again, the fluid effused in inflammation of 
the pleura, occurring in a person of previously good health, is highly 
plastic, whereas the fluid effused under the same circumstances in a 
debilitated subject, contains little or no fibrine, but becomes speedily 
puriform ; it follows from this, that independently of the nature of 
the tissue affected, the character of the effusion is greatly influenced 
by the state of the blood, of the nervous force, or general health of 
the patient. 

Besides these conditions, the character or intensity of the inflam- 
mation will often determine the nature of the effusion; thus we 
know that the skin, under inflammation of what is termed a specific 
character, as eczema, herpes, small-pox, and erysipelas, effuses the 
corpuscular lymph alone, though that tissue, in its normal state, 
pours out fibrinous lymph in common inflammation; whereas the 
mucous membrane of the trachea will, on the other hand, pour out 
plastic fibrinous lymph under the intense inflammation of croup. 
There are then three conditions influencing the character of the in- 
flammatory exudation: — 



VAKIETIES OF INFLAMMATORY LYMPH. 53 

(1.) The nature of the part or tissue that is the seat of the inflam- 
mation. 

(2.) The state of the blood and general health. 

(3.) The character and intensity of the inflammation. 

Mucus is another substance which has been reckoned among the 
products of inflammation, though there is little doubt that, in the ma- 
jority of instances, the apparently increased quantity of mucus poured 
forth from a mucous membrane, in which inflammation has been 
established, is owing mainly to the inflammatory lymph mixing with 
the natural secretion of the part though, no doubt, the secretion of 
proper mucus is often increased likewise, and with it the quantity of 
epithelium, with which are mixed immature epithelial cells. 

It appears probable that too much stress has been laid by sys- 
tematic authors, upon the essential difference between the product 
of inflammation in a serous and a mucous membrane ; for in an 
established inflammation of one of the latter, there appear the ordi- 
nary products of inflammation of serous membranes and other parts ; 
the difference consisting only in the fluid in which they lie. Their 
increased proneness to degeneration, and consequent diminished 
susceptibility of development when so mixed, produce a greater 
tendency to puriform effusions from mucous surfaces than from other 
textures. 

The inflammatory lymph, in its progress towards degeneration or 
development, undergoes changes, the history of which constitutes a 
most important part of the doctrine of inflammation. 

The inflammatory lymph, like the blood from which it is separated, 
has a life of its own, and is capable of acting as a blastema, originat- 
ing new formations independently of the blood-vessels, although the 
presence of the latter constitutes one of the conditions without which 
that life cannot be indefinitely prolonged. It is also necessary to 
bear in mind that the progress of the inflammatory lymph towards 
more complete organization cannot commence until the inflamma- 
tion subsides, as before that happens, fresh lymph will be continually 
poured out, and that already effused may undergo degeneration but 
never development. 

The fibrine of the effused lymph, after its first coagulation, is of a 
soft, flocculent, or semigelatinous consistence; it soon, however, 
evinces a remarkable tendency to shrinking, or rather contracting 
in bulk, owing to which we find not only an increased hardness of 
different structures as one of the consequences of inflammation, but 
a remarkable drawing together of the parts into which the effusion 
has taken place, or shrinking of the surface upon which it has been 
deposited. After some time red striae may be observed in the new 
product, appearing like continuation into it of the vessels of the tissue 
from which the lymph had been effused. It has been much ques- 
■ tioned whether these vessels are really prolongations of those of the 
original tissue, or whether they are formed de novo from the effused 
cytoblast. The latter is the opinion of Vogel, who states that he has 
arrived at it through a large number of observations, and adds that 
it is only at a later period that they connect themselves with the 



54 ITS SUBSEQUENT CHANGES. 

previously existing normal vessels; the blood which they contain 
before uniting with the latter vessels being probably produced anew 
in the same manner with themselves. Professor Paget, on the other 
hand, maintains that all the vessels in inflammatory lymph are formed 
by outgrowth of adjacent vessels, in which opinion he is supported 
by Mr. Travers, Mr. Quekett, and others, and it cannot be denied 
that there are many sources of fallacy in the observations by which 
the opposite opinion is supposed to have been established. At the 
same time that these vessels are being formed, the fibrinous lymph 
passing through the stage of a nucleated blastema, assumes the cha- 
racters of the fibro-cellular or areolar tissue of the body, and its 
organization may be said to be completed. 

The corpuscular lymph, though more prone to degeneration than 
the fibrinous, is also capable of organization, which is generally 
effected, according to Professor Paget, through the elongation of its 
cells, and it is through the development of these cells that granula- 
tions, hereafter to be described, are produced. Besides the fibro- 
'ellular tissues, there are two other structures which may be formed 
zrom lymph, namely, epithelial cells, and bone; the first of these 
are formed in the skinning of superficial wounds and sores, and on 
membraneous inflammations ; the latter is formed from lymph effused 
in inflammations occurring in or near the periosteum ; the earthy amor- 
phous deposits occurring in false membranes formed by the organiza- 
tion of inflammatory lymph, and which are the result of the subse- 
quent degeneration of such tissues, are to be distinguished from the 
products of the ossific inflammation. 

Besides these changes, which constitute the development of inflam- 
matory lymph into organized tissues, constituting integrant parts of 
the living body, others may occur, by which it retrogrades into sub- 
stances of a lower degree of vitality less removed, that is, from in- 
organic matter, and consequently, more prone to disintegration, but, 
at the same time, more susceptible of absorption. A brief enumera- 
tion of these changes will greatly aid the explanation of several of 
the consequents of inflammation ; though for a more complete account 
of them the reader is referred to the admirable lectures of Professor 
Paget, already quoted. 

(1.) It may undergo a simple wasting or drying; the fibrine 
showing no tendency to organization, but becoming merely closer 
and firmer. 

(2.) A very important degeneration to which the fibrine of the 
effused lymph is liable, is a change closely resembling the fatty de- 
generation in muscular fibre, which has been long known to patho- 
logists as a simple lesion of nutrition, and one to which the last 
named tissue is peculiarly liable in old age. In the lymph poured 
out in the lower forms of inflammation, or in very unhealthy sub- 
jects, minute drops of oil may not unfrequently be detected ; while 
the fibrine of the lymph is very soft, and easily broken. This oily, 
or fatty matter, with the ill-formed fibrine by the degeneration of 
which it is produced, is the principal constituent of the " aplastic 



INFLAMMATORY DEGENERATIONS. 55 

lymph" effused in inflammations of serons membranes in unhealthy 
subjects, and " to the same source," as observed by Professor Paget, 
"we may trace most of that molecular and granular matter which is 
usually mingled — with pus formed by the suppuration of inflamma- 
tory indurations, — with the variously-changed corpuscles of scro- 
fulous matter, — or with the granule-cells, and other corpuscles of 
pneumonia and the like inflammations ; at least, this disintegration 
of fibrine is probably a frequent origin of such molecular matter ; 
while the quantity of fatty matter present in pus and the products 
of pneumonia, and its gradual increase while pus is retained in an 
abscess, confirm the view that the changes here described are of the 
nature of fatty degeneration." It is very probable, and, moreover, 
important to be remembered in practice, that this degeneration of 
fibrine into a lower organic product, fat, is highly beneficial, bring- 
ing the lymph into a state more susceptible of absorption, and thereby 
facilitating resolution, the most favourable termination of inflam- 
mation. 

Another change is the calcareous degeneration, of which we see 
traces on the valves of the heart and on the surface of the pericar- 
dium, though this change is less frequent in the fibrine, than in 
more advanced products of inflammation. 

Another degeneration is the pigmental. 

The corpuscular lymph is also liable to undergo degenerations 
similar to those which have been already described as occurring in 
the fibrinous exudations ; thus the corpuscles may wither and dry 
in any stage of their development, as in the cheesy, ochre-coloured 
scrofulous matter. 

The fatty degeneration of corpuscles is shown in their transition 
into granule-cells, and may appear at almost any period of their de- 
velopment ; and it is probable too that, as in the case of fibrine, this 
change is a step towards the absorption of the lymph. We pass on, 
however, from these, to speak of the most important and most fre- 
quent degeneration of lymph-cells, viz., the puriform, or in fact of 
the process of suppuration. 

It may be well to state, first, that pus is an opaque and homo- 
geneous fluid, of a creamy consistence, pale-yellow, or rather yel- 
lowish-drab colour ; it has a greasy feel when rubbed between the 
fingers, and when fresh and warm, it has a very slight, mawkish 
odour fa tjzwta $v<sa>8ri$)' its specific gravity is from 1030 to 1033. 
Such is the pus formed in healthy wounds, or in mature abscesses, 
which may be regarded as the normal, or standard pus — the "pus 
laudabile" of the older authors. 

This fluid, though apparently homogeneous, consists, in reality, of 
two parts — a colourless serous fluid — and minute organised bodies, 
the corpuscles of the pus. 

The fluid or serum of the pus is in all respects the same as serum 
of the blood. The corpuscles are of greater specific gravity than the 
serum in which they are suspended, varying in size from the s ^ to 
the 3J0 of a line in diameter, and are, for the most part, organised 



56 SUPPURATION". 

cells, consisting of a cell- wall, with a nucleus attached to its inner 
surface. 

These corpuscles were at one time supposed to be altered blood 
corpuscles ; but there is every reason to believe that they are, in the 
majority of cases, as has been shown by Professor Paget, formed by 
the degeneration of the corpuscles of the corpuscular lymph ; though 
it is apparent, from instances which he has himself adduced, that the 
fibrine of the fibrinous lymph is also susceptible of a similar de- 
generation. 

The process of suppuration ordinarily assumes one of the following 
forms, depending in a great measure upon the tissue involved. 

When a considerable extent of areolar tissue has been inflamed, 
the part after having been red, swollen, and oedematous, becomes 
hard towards the circumference, and softer and boggy towards the 
centre. This indicates that pus is about to be deposited in a reservoir 
surrounded by a wall of fibrinous or coagulable lymph. 

It may be observed, that in this case we have the two different 
forms of inflammatory lymph. At the circumference we have the 
fibrinous variety, the fibrine of which, becoming solid in the cells of 
the areolar tissue, forms the wall of the abscess ; and in the centre 
the corpuscular variety, the corpuscles of which speedily undergo 
the puriform degeneration. ISTow the effect of pus diffused through 
a tissue is to soften it, and as it were to substitute itself for it, so that 
there remains a central portion consisting wholly of pus; the con- 
sequence of which is, that we have a stroma or sac of solid fibrinous 
matter, and a contained portion consisting of pus — this is an abscess. 

The difference in the situation in which these two results of in- 
flammation show themselves, throws some light upon the circum- 
stances which determine the one rather than the other. In the 
portion of the inflamed part which is nearest to the vessels and 
nerves of the healthy tissues (that is in the circumference) we have 
the effusion of fibrinous lymph, and consequently, the plastic result of 
inflammation: in that part, on the contrary, which is the furthest 
removed from healthy nerves and vessels, and towards which the 
passage of the blood must be most obstructed, as it has to reach it 
through a greater extent of inflamed tissue — (i. e. in the centre), we 
have the effusion of corpuscular lymph degenerating into the non- 
plastic product of inflammation — pus ; thus exemplifying, or rather 
illustrating, the opinion of Hunter, that "the new-formed matter 
peculiar to suppuration, is a remove further from the nature of the 
blood than the matter formed by adhesive inflammation." 

It may happen, however, that an abscess shall be formed from the 
softening, from the centre, of a part that has become indurated by 
inflammation ; that is to say, throughout the whole of which fibrinous 
lymph has been deposited : showing that the fibrinous variety of in- 
flammatory lymph may, under some circumstances, be converted into 
pus, though far less liable to that degeneration than is the corpuscular. 

In the general softening and solution of the tissues which take 
place in the formation of an abscess, the blood-vessels are destroyed 
like other textures, their truncated extremities being closed by co- 



ABCESS. 57 

agulable lymph, whilst the capillaries of the adjoining part, which 
remain pervious, are seen to be dilated, and ramifying on the walls 
of the abscess. Whilst the inflammation continues the effusion of 
lymph continues also ; and as this lymph is of a corpuscular cha- 
racter, it speedily undergoes a puriform degeneration, hence these 
vessels have been said to secrete pus; and the lining, or the inner 
surface of the abscess has been called a pyogenic membrane, though 
there is in reality no membrane adapted to the special purpose of 
secreting pus. As the pus increases the abscess enlarges itself, 
generally in the direction of a neighbouring cutaneous or mucous 
surface ; and as it approaches this, a feeling of fluctuation may be 
perceived, and when it reaches the inner surface of the integument 
it is said to point ; and if the abscess be not now opened by the 
lancet the integuments ulcerate, and the pus is discharged.* 

It is doubtful whether this extension of the abscess depends upon 
an intersticial absorption, the result of inflammation of the contiguous 
parts, or whether some of these parts are separated, and being cast 
loose, as it were, into the cavity of the abscess, soften down into pus. 
It is certain, however, that the tissues of the part are undergoing a 
process rendering them susceptible of intersticial absorption, since 
continuance of inflammation is essential to the progress of an abscess 
towards the part where it is about to open. 

We may observe, that in order to the formation of an abscess, 
besides the formation of pus, a sufficient amount of fibrinous or 
plastic effusion is necessary to form the cyst or wall, and prevent the 
diffusion of the pus into the surrounding tissues. It does sometimes 
happen, accordingly, in low inflammation in unhealthy subjects, 
though there being little or no fibrinous effusion from the part, that 
the corpuscular lymph rapidly degenerates into pus, constituting 
what is termed purulent infiltration. And when this occurs in the 
areolar tissue, the consequences are most disastrous ; for there being 
nothing to oppose the diffusion of the pus, suppuration of an un- 
healthy character, attended with destruction by sloughing, of the 
part involved, spreads rapidly through an undefined extent of areolar 
tissue. This has long been known by the name of diffused inflam- 
mation of the cellular membrane, and is attended by the greatest 
danger, the accompanying fever being of a low typhous character, and 
the extension of the mischief sometimes ceasing only with the life of 
the patient. 

The opening of an abscess, if it be not effected by the lancet, has 
already been stated to take place by intersticial absorption and 
ulceration, of which it is necessary now to speak a little more par- 
ticularly. 

One of the most frequent effects of inflammation is a softening of 
the part affected, not only from its infiltration by fluid, but also from 
a tendency to disintegration, which may be regarded as an instance 
of degeneration during the inflammatory process; but, as Professor 
Paget observes, " a more general and more unmixed form of de- 

* Williams' " Principles of Medicine." 



58 ULCERATION. 

generation may be occasionally observed in the tissues of inflamed 
parts, viz., fatty degeneration ; and this in such a manner as to make 
it probable that the degeneration takes place even during the in- 
flammation." 

Both these changes favour the removal by absorption of the in- 
flamed part, constituting what we have before spoken of as inter sticial 
absorption, and which is to be distinguished from the ejection of 
particles from the surface occurring in what we now proceed to 
speak of under the term ulceration. 

We have already seen that the effusion of pus is always attended 
with more or less absorption, not only of the effused fluid and of the 
lymph which encloses it, but also of the surrounding tissue; and, it 
not uncommonly happens, more especially in the advanced stages of 
inflammation, that this process takes place in a degree greatly dispro- 
portioned to the effusion, and far beyond what is requisite for giving 
exit to the non-plastic product ; but also the superficial particles of the 
inflamed part are ejected externally — this is ulceration. It may happen, 
moreover, that the abscess has reached the surface, or has commenced 
very near it ; or that a part of the tissue forming the surface — a mucous 
membrane for instance — has become the seat of inflammation and the 
superficial particles ejected, and thus a small open abscess, which is in 
fact an ulcer, is formed. We may then have the process, which has been 
described as going on in an abscess towards the surface, taking place 
in an opposite direction, ovfrom the surface ; and in the more healthy 
forms of ulceration there is a stroma or layer of fibrinous lymph 
deposited, which forms the cup or floor of the ulcer ; and this stroma 
being continually removed, either by intersticial absorption, as in 
the case of the abscess, or ejected from the surface by the more 
strictly ulcerative process, is continually replaced by a deeper floor 
or cup, which is in its turn again removed ; and this process may go 
on to any extent, removing in its course any tissue that may chance 
to traverse it, though some, as the walls of blood-vessels, are more 
slowly removed than others. This process is, however, as above 
described, preceded and attended by the effusion of lymph, which is 
being continually removed ; and the more rapid is the absorption in 
proportion to the deposition, the more extensive and destructive is 
the ulceration. It may, however, happen that in some points the 
effusion of lymph takes place more rapidly than its absorption, and 
thus are formed those little eminences which quickly become organised 
and vascular, and are termed granulations. By the irregular growth 
of these granulations, and the irregular or varying extent of the 
ulcerative absorption, the surface of an ulcer is necessarily rendered 
uneven; and ultimately its healing is effected by the process of ex- 
udation of plastic lymph and its consequent organisation prevailing 
over the contrary process of absorption ; a result which, it must be 
apparent from what has already been said, can be brought about 
only by the suppression of the inflammation. 

Thus far we may perceive an exertion of plastic power for the 
purpose of repair, and that a wall of defence is being continually 
opposed to the destructive process, preventing the infiltration of pus 



GANGRENE. 59 

into the surrounding tissues. It may happen, however, and not very 
rarely does, that there is not sufficient plastic power for this purpose, 
and the result is an ulcer without any cup or floor of lymph — this 
15 the phagedenic ulcer. 

Sometimes again, the effused matter forming the cup of the ulcer 
becomes indurated, and there is very little effusion of lymph, and 
little or no granulation. Such an ulcer is not unaptly described by 
the term indolent ; or the granulations may be too large and soft ; 
lymph, indeed, is effused in abundance, but it appears to be deficient 
in plastic property, probably from a preponderance of the corpuscular 
over the fibrinous form of exudation — such is the spongy ulcer. 

There is still one step further in the destructive action of inflam- 
mation. This takes place when the increased vascular action attend- 
ant upon the first stage of inflammation is followed, or rather accom- 
panied, by a rapid exhaustion of the vital force, so rapid, that it 
speedily ceases altogether, and the part dies — this is gangrene. It 
fortunately happens that this does not commonly take place through- 
out the whole inflamed tissue or organ, but that part which has been 
the most inflamed becomes soft and flabby, and then gradually 
changes its color to a livid or black, and ultimately emits a putrid, 
cadaveric odor: this is more especially the case in that form of 
gangrene which is the direct result of inflammation ; but when the 
mortification is of the character often termed dry gangrene, as from 
obstruction of an artery or from the use of diseased grain, there is 
commonly no blackness or lividity. Mortification, or gangrene 
occurs most often either on the surface or extremities of the body, 
in the lungs, in the mucous membrane of the alimentary canal, par- 
ticularly the stomach and large intestines, and in the peritoneum, 
rarely in the other internal parts, except as the result of injury. 

Gangrene has a tendency to diffuse itself through any part which 
is affected by it; fortunately, however, it generally happens where 
the inflammation has been less intense, or the living power greater, 
as in the part nearest the heart, that plastic lymph is thrown out, 
forming a stratum, or wall, by which the gangrenous structure is 
separated from the rest of the body ; and, the affected part being 
separated from the surface of this layer, is said to come away by 
sloughing. When, indeed, the vital powers are very feeble, or the 
circumstances attending the infliction of the injury which caused the 
inflammation have been such as to give a powerful depressing shock 
to the system, there may not be sufficient power to produce this pro- 
tecting wall of adhesive matter ; and the gangrene, spreading rapidly, 
is arrested in its progress only by the death of the patient. 

The conditions which induce this most destructive result of 
inflammation, are such as most impair the living power of the part 
affected, or of the system at large. Among the former may be 
reckoned, violent mechanical injury, intense heat or cold, and certain 
poisons (among the latter, the morbid poisons of plague, typhus fever, 
scarlatina, erysipelas, &c); affections of the heart or large vessels 
obstructing or enfeebling the circulation, and of the nervous centres, 
impairing the vital powers ; to these may be added, perhaps, the 



60 INFLAMED BLOOD. 

injudicious use of mercury, or other remedies which diminish the 
quantity of the fibrine, or lessen its coagulating property. 

It may be observed that, as ulceration consists (in a great degree, 
at least), like sloughing, of a separation outwardly of the diseased 
tissue, in contradistinction to its being taken up, into the system, by 
the process which we have spoken of as intersticial absorption, it 
may be said to differ from the latter rather in degree than in kind : 
but there is this further distinction, that in ordinary ulceration, after 
the ulcer has been established, portions of the affected tissue cannot 
be recognized in the discharge from the ulcer ; so that, in order to 
its removal, it must have previously undergone a molecular disinte- 
gration, or subdivision ; though in the commencement of the process 
a visible slough is cast off: or, in other words, there is gangrene upon 
a small scale. 

The disturbance caused by inflammation is not, however, confined 
to the part of which it is the seat ; the blood throughout the system 
undergoes the changes which have been already described (p. 46) ; 
with the exception already noticed, that, whereas in the seat of the 
inflammation there is an increase in the proportion of the red cor- 
puscles, they are diminished in the blood circulating through the 
system. The increase in the quantity of the fibrine always takes 
place when there is sufficient inflammation to give rise to febrile 
symptoms, although its actual percentage may be, in some degree, 
affected by the previous condition of the patient : thus in typhus fever 
the proportion of fibrine is always small, sometimes as low as 1 per 
1000 ; yet if, during this disease, inflammation be set up in any organ, 
the proportion of fibrine increases, though not to the same amount 
as under other circumstances, never reaching a higher proportion 
than 5 per 1000, whereas in ordinary inflammations it almost always 
exceeds that amount, and, in some specific ones, as acute rheumatism, 
it reaches 8 per 1000 ; so that we perceive the constant association 
of an increase of the quantity of the fibrine with acute inflammation, 
although there may be at the same time in operation other causes 
which have an opposite tendency* 

When, again, the system is weakened by any continued chronic 
disease, or if there be from any other cause a less degree of anaemia, 
as in chlorosis, it will nevertheless happen that the fibrine will be 
increased under the influence of inflammation, and attain as high a 
proportion as in a subject previously healthy ; neither is there any- 
thing in this contrary to what might have been expected, since, in 
such cases, it is the corpuscles alone which are deficient, the fibrine 
varying scarcely at all from the normal standard : indeed, by reason 
of the constant deficiency of the red corpuscles, there must be, in 
anaemia, a relative excess in the proportion of the fibrine ; so, 
whether in chlorosis or in that state of anaemia which is induced 
towards the close of many protracted diseases, there must exist a 
condition of the blood approaching very closely to that which occurs 
in inflammation, a circumstance tending to explain what clinical expe- 

* Andral, " Hsematologie." 



INFLAMMATORY FEVEE. 61 

rience teaches by observation, that inflammation is very apt to super- 
vene upon the condition of anaemia. 

In addition to these changes, there is always, in active inflamma- 
tion of any extent, and in good constitutions, a general disturbance 
of the system, commencing most commonly with a feeling of chilli- 
ness and lassitude, with headache, and pains in the limbs, followed 
by increased heat of surface, frequency and fulness of the pulse, 
thirst, a furred or a white, and, in the first instance, moist tongue ; 
scanty and high-colored urine ; and sometimes delirium. This 
general excitement is termed inflammatory fever. 

This description of inflammatory fever is, however, strictly appli- 
cable only to healthy inflammation, occurring in the healthy subject, 
and as observed during its progress to its full development ; its char- 
acter being materially influenced by the stage and duration, as well 
as by the seat of the inflammation, and also by the age and condi- 
tion of the patient. 

Now the fever has been described as following the local inflamma- 
tion, and as being brought about by the change in the condition of 
the blood, a change probably commencing in the inflamed part : this, 
however, is strictly true only of those inflammations which are 
brought about by direct external injury ; for there are many cases, 
those especially in which the inflammation is the effect of cold, 
where the general fever unquestionably precedes the local inflamma- 
tion, and that, too, in parts exposed to view, as the tonsils and 
mammae, in which the commencement of the inflammation could not 
easily have been overlooked. Now there are, undoubtedly, many in- 
flammations which are the effect of poisons introduced into the system, 
which poisons (as in the case of small-pox) often evince a remarkable 
tendency to reproduce and localize themselves in particular parts or 
tissues. This is more particularly the case of animal and morbid 
poisons, and in such cases, as the poison must have been present in 
the blood before giving rise to the local inflammation, we need be at 
no loss to account for the antecedent febrile disturbance ; and others, 
again, although not capable of reproducing themselves like the 
specific morbid poisons, evince a no less remarkable tendency to 
localize their effects upon particular tissues, as in the case of arsenic, 
applied to an abraded surface, creating inflammation of the stomach, 
though we are at present unable to explain the manner in which 
this peculiar determination takes effect. And to take the case of 
cold applied to the surface, we know that even in this instance there 
must be an alteration in the secretion, circulation, and nutrition of 
the skin, and as such alteration, whether in the secretion or nutrition, 
cannot take place without a corresponding alteration in the condition 
of the blood, (brought about by the presence in that fluid of materials 
destined for the supply of the nutrition or secretion of the part whose 
functions have been thus interfered with,) there may be thus induced 
a state of the blood capable at the same time of exciting general dis- 
turbance in the system, and ultimately inducing inflammation, by 
the abnormal matter localizing itself, and exciting irritation in any 



62 INFLAMMATORY FEVEK. 

particular part .* This, perhaps, is the way in which we may explain 
the fact of the general fever sometimes manifesting itself before the 
local inflammation. 

The character of the fever is, as we have said, modified by the 
period of the local inflammation, and, alter some of the consequences 
of inflammation above described have been established, it undergoes 
a material change, the nature of which depends, in many instances, 
upon the organ affected, and will be described in connexion with the 
special inflammation ; but the very striking and common change, from 
the continued to the remitting character of fever, belongs especially 
to a particular stage. This form of fever is the hectic, which is 
generally associated with the formation of pus, and accompanies the 
process of suppuration or ulceration. Its commencement is often 
marked by a distinct and severe attack of rigors, after which the 
fever becomes remittent. There are often chills in the afternoon, 
which are followed in the evening by heat of skin, — great flushings 
in the face, often with a remarkable pink patch in the cheeks, — 
thirst, — anorexia, — and furred tongue : as night advances, the patient 
perhaps falls asleep, and awakes early in the morning bathed in 
perspiration; this is accompanied by a sense of great languor, and 
followed by an abatement of the fever, which returns in a similar 
manner in the afternoon; the pulse, however, continuing frequent 
throughout. There are sometimes two or three paroxysms during 
the twenty-four hours, and it is worthy of note, that the paroxysms 
and remissions may take place still more irregularly, consisting, in 
some instances, merely of frequent flushings. This, perhaps, oftenest 
occurs when the effused inflammatory product has been gradually 
undergoing a transition to the puriform character. When the hec- 
tic continues, which it generally does unless the suppurating part 
be healed, debility and emaciation steadily increase — the tongue 
becomes vividly red and glazed, and subsequently it, as well as the 
lining membrane of the fauces, is covered with little points of sup- 
puration, termed aphthaa — diarrhoea, with increased exhaustion, 
succeed, and the patient sinks, though in general with but little or 
no delirium or sensorial disturbance till the very last. 

Sometimes, again, the change in the character of the fever is of a 
different nature, arising from its assuming more of the low, powerless 
type, denominated typhoid. This is indicated by a brown and dry 
tongue, dusky skin, feeble and incompressible pulse, and in bad 
cases, low, muttering delirium. But, whatever be the nature of the 
change in the character of the fever, it is of the greatest importance 
to observe it, since, if there be evidence from other sources of the 
continuance of the inflammation (or rather, if there be no satisfactory 
evidence of its subsidence,) it indicates a change from the plastic pro- 

* Those who have ever considered the minute exactness which must exist, in health, 
between the blood and the tissues, will not be surprised that any, even the most minute, 
alteration of this adaptation, may become a source of disease, or that the abnormal 
matter or diseased action should localize itself in any particular part or tissue. — Vide 
Paget on Nutrition, " Med. Gazette," 1841 ; "Brit, and For. Med. Chir. Rev." vi., p. 
406 1 and Dr. W. Budd on Symmetrical Diseases, "Med. Chir. Trans." xxv. p. 100. 



INFLAMMATORY FEVEE. 63 

cess of adhesive inflammation to the destructive one of suppuration, 
or liberation, a change which calls imperatively for an alteration in 
our remedial measures. 

The character and symptoms of the fever are also materially influ- 
enced by the age and constitution of the patient. Thus, in persons of 
advanced age, or of constitutions impaired by bad or intemperate 
living, the fever will often be of the low or typhoid type, and there 
will be almost from the first a brownish tongue, feeble compressible 
pulse, and generally prostrate condition of the system. Whereas in 
the younger and more robust we shall have a greater hardness of the 
pulse, with a dry tongue, and greater heat of surface; and these 
symptoms of active fever will often be observed to persist after the 
more urgent ones of the local disease have begun to subside. 

The febrile symptoms are still further modified by the seat of the 
disease. Inflammation of the tonsils and of the serous and synovial 
membranes, is attended with a more active fever than that of the 
parenchymatous viscera, and inflammation of the latter than that of 
the mucous surfaces. Inflammations of the brain, of the pericardium, 
and of the intestines, produce remarkable modifications of the pulse, 
to be noticed hereafter. 

In taking a review of the inflammatory process, it may be important 
for practical purposes to make a few observations upon the effects 
which it produces upon the living powers. 

Now, as regards the part itself which is the seat of the inflamma- 
tion, it may be remarked, that the term increased action, so freely 
used by writers upon this subject, must be taken in a very qualified 
or restricted sense, for though there is, while the inflammation lasts, 
an increased afflux or determination of blood to the part, there is no 
increase of the vital process of nutrition; on the contrary, so far from 
there being any hypertrophy or increased formation of the natural 
tissues of the inflamed part, we have an opposite tendency ; the tissues 
waste, or become soft, relaxed, and weakened ; they degenerate, and 
are lowered in functional power, or become absorbed ; they die and 
are cast out from the system. 

We perceive then that, as regards the part itself, the effect of inflam- 
mation is rather to depress than to exalt its vitality; and the same 
may perhaps be said of the attendant fever, upon the system at 
large; whilst this fever lasts the waste of the body often goes on 
with increased rapidity, and its nutrition being checked, its renewal 
is arrested until the inflammation has subsided. 

As regards, however, the products of the inflammation, or the new 
matter which is generated in and around the inflamed part, we often 
have indeed an increase in bulk and weight ; but as regards this new 
matter it should be remembered, that even when it becomes organ- 
ized, no other tissues are ever produced but those which are lowest 
in the scale of vitality, viz., bone and areolar tissue; and that the 
effused lymph cannot assume even this degree of organization until 
the inflammation has subsided ; whereas, if it be excessive, or very 
long continued, the organization is ultimately entirely frustrated. 



64 INFLAMMATORY FEVER. 

The immediate or proximate causes of inflammation must be 
sought for in the disturbance of those conditions essential to healthy 
nutrition, of which we have seen inflammation to be a perversion, 
although it may be doubted if each, or even any of these is capable 
of singly producing inflammation. Thus changes in the blood-ves- 
sels affecting the free transit of blood through them, are capable of 
producing an imitation of some of the phenomena of inflammation, 
as in the effusion of liquor sanguinis, which sometimes assumes the 
form of inflammatory lymph, and undergoes partial organization; 
but, beyond this, we do not find that simple distention of the blood- 
vessels, as that produced by mechanical obstruction, is capable of 
alone producing the phenomena of inflammation. 

Changed condition of the blood itself has undoubtedly a more cer- 
tain tendency to produce inflammation, than has that of the blood- 
vessels ; and it is highly probable that the majority of the so-called 
constitutional or idiopathic inflammations have their origin in the 
blood. This we know to be the case in the eruptive fevers, where the 
presence of a morbid matter may be proved by their communicability 
by inoculation ; and though it may not have been actually demon- 
strated, there can be little doubt that the same is the case with rheu- 
matism, gout, erysipelas, eczema, and similar affections generally called 
constitutional. 

As regards the due influence of the nervous force, we have seen 
from instances already adduced that its disturbance may excite 
inflammation, and more will probably be mentioned hereafter; at 
the same time there is no reason for adopting the hypothesis that 
the phenomena of inflammation are brought about solely through 
the medium of nervous influences, since they may be excited in 
parts that have no nerves. 

As the nutrition of a part is maintained by the mutual interaction 
of the blood and the tissues of that part, it must follow that an altered 
condition of the part itself must interfere with its healthy nutrition, 
and therefore we might expect, from analogy, that the phenomena of 
inflammation might arise from the same cause, the more so as we 
know that "it is the state of an injured part, or of its proper tissues, 
not of its nerves and vessels, which determines the process of repara- 
tion ; and some of the processes of repair are so like those of inflam- 
mation, that they are commonly identified, and are, perhaps, not 
capable of even a refined distinction."* 

* Paget, "Lectures on Inflammation.'* 



SIGNS OF INFLAMMATION. 65 



V. 

SIGNS OF INFLAMMATION, AND OF DISEASE IN 

GENEKAL. 

The symptoms of inflammation require to be treated of in this 
place, although some of the remarks which we shall have occasion to 
make will be equally applicable to those of disease in general. They 
have been commonly described as local and general, but there exist 
some objections to this arrangement, inasmuch as the so-called local 
signs are often not seated in the part affected, but, on the contrary, 
manifest themselves in others remote from it; nor indeed are they 
always confined to any fixed part, since the derangement produced 
by the impaired function, consequent upon the disease of a vital 
organ, must be perceptible over the whole of the system. We 
therefore prefer to class them, as 

I. Primary and local. 

II. Secondary and sympathetic. 

III. General and febrile. 

(1). When the inflammation (or other disease) is seated in ex- 
ternal parts, the local symptoms are so obvious as to require no 
description. 

It is when there exists deep-seated inflammation, more especially 
in any of the great cavities of the body, that there often arises con- 
siderable difficulty not only in determing its seat but in ascertaining 
its existence; and this difficulty constitutes one of those problems 
the solution of which is the special province of the practice of medi- 
cine. I. The primary and local signs of inflammation consist in the 
alterations in the sensibility and physical condition of the part, and 
in derangement of its functions. II. The secondary consist in de- 
rangement of the sensations or functions of remote parts. III. The 
general and febrile are the inflammatory, irritative, and hectic fevers 
already described. It is to the first of these that our attention is 
directed by the definition of internal inflammation given by Cullen, 
viz., "fever with fixed pain in some internal part, and deranged func- 
tions in some external organ." Now as regards the pain, though it 
is almost always the first symptom to which our attention is directed, 
and often one of the most urgent; yet it is perhaps the most fal- 
lacious of the signs of inflammation, for not only does it vary very 
greatly according to the structure of the part inflamed, independently 
of the intensity of the inflammation, but besides this, we may have 
severe pain without inflammation, and inflammation, of an intense 
and dangerous character, without pain. Thus pain is severe in in- 
flammation of the serous membranes (with the exception, perhaps, 
of the pericardium and lining membrane of the heart and arteries); 
less so in inflammation of the mucuous membranes; and so slight, 
or so frequently altogether absent, in inflammations of the paren- 



6Q PAIN — TENDERNESS. 

chymata of the viscera as to render it possible that when present it 
is dependent upon the implication of some membranous stricture in 
the inflammation. The pain also resulting from slight inflammation 
of the walls of the great cavities, as well as neuralgic pains, in- 
dependent of any inflammation, may often equal in intensity that 
arising from the most acute. 

There is, however, another modification in the sensations of the 
part, from which we may, where it is applicable, often learn as much 
or even more than from pain, and that is tenderness. It is very true 
that there may be an exalted sensibility, especially of the surface, 
without any inflammation, as in the case of the tenderness of the in- 
teguments in the early stages of continued fever, and of that which 
sometimes accompanies neuralgic pains in irritable subjects ; it may 
also be present as a peripheral manifestation of some inflammation 
or irritation of the nervous centres, the brain, and the spinal cord. 
Still, where it is possible to apply pressure to a deep-seated part, as 
in the case of the abdominal viscera, the tenderness so detected may, 
in connection with other symptoms, be a great help to us in deter- 
mining: the existence or seat of the disease, and afterwards in esti- 
mating its progress. This is particularly applicable to inflammation 
of the mucous membrane of the intestines, where the pain complained 
of may be very slight, although upon cautious and deep-applied pres- 
sure there may often be found to be considerable tenderness: the 
same holds good also in some degree in inflammation of the liver, 
kidneys, and bladder. In inflammation of the peritoneum it affords 
great assistance in determining its extent and progress. Care, how- 
ever, should always be used that, in making pressure to ascertain 
the presence or absence of this symptom, we do not inflict injury 
upon parts rendered more than usually susceptible of it by disease. 

There is, again, another way in which this tenderness manifests 
itself, and that is in the impediment it causes to the movement of 
parts connected with the seat of the inflammation, or the pain which 
it causes by their being brought into certain positions relatively to it. 
Thus, when the larynx is inflamed, we have often difficulty in de- 
glutition or swallowing ; when the pleura, a deep inspiration or cough 
causes pain ; and the same is the case in inflammation of the perito- 
neum, owing to the tenderness of the inflamed membrane being 
excited by the descent of the diaphragm, the respiration being at 
the same time rendered thoracic; this latter symptom is also not 
uncommonly present, from a similar cause, in inflammation of the 
pericardium. 

In addition, the signs which may be derived from the feelings of 
the patient are those presented to the senses of the observer ; and 
where these can be applied, which, owing to comparatively recent 
improvements in the art of diagnosis, they now can be to a much 
greater extent than formerly, they become of more importance than 
the preceding. The most obvious instances of change in the sensible 
properties of a part, are the redness, heat, and swelling which may 
be seen or felt in parts which are immediately accessible to the sight 
or touch. But it is not only by the senses of sight and feeling that ^ 



PHYSICAL — FUNCTIONAL SIGNS OF DISEASE. 67 

we are enabled to detect changes in the size or consistency of in- 
ternal parts ; the sense of hearing will be found most materially to 
aid us, and that too in parts situate within the bony walls of the 
chest, and consequently inaccessible to the touch. Thus, when the 
lungs are rendered more dense from the plastic effusion of inflamma- 
tion, the sound elicited by striking the surface overlying the inflamed 
part will be duller than it would have been in health ; a similar 
result, though from a different cause, is produced when inflammation 
of the pleura has given rise to effusion into the cavity of that mem- 
brane; and even in the abdomen, where we can in some measure 
apply the sense of touch, the variations in the resonance will greatly 
aid us in detecting enlargements and effusions, whether inflammatory 
or otherwise. 

But besides this, the senses of the observer may be applied to 
detect the alterations which are produced by inflammation in the 
sensible phenomena which accompany the action of those parts. Thus, 
not only do inflammations of the heart and large arteries make the 
pulsations violent and irregular, but the sounds accompanying them 
are greatly altered from what they are in health. Again, in inflam- 
mations of the lungs, air-passages, or pleura, not only is the respira- 
tion quickened, and in some cases rendered painful, but the sounds 
which accompany breathing, coughing, or speaking, as heard by 
listening on the surface of the chest, are essentially different, as one 
or other of these structures is affected, and according to the extent 
and stage of the inflammation. 

Another sign of disease, and one which is, perhaps, of greater im- 
portance than any of the preceding, is the impaired or perverted 
function of the part or organ. Inflammation of the nervous centres 
may give rise to disturbances in the intellectual, sensorial, or volun- 
tary functions, consisting of delirium, excessive sensibility, loss of 
sensation, increased mobility or spasm, and loss of voluntary motion. 
In inflammation of the lungs we may have not only the hurried and 
altered respiration before alluded to, but also a defect in the special 
function of those organs, namely, the decarbonization of the blood ; 
hence the dusky hue of pneumonia. When the liver or the kidneys 
are inflamed, we may have suppression or diminution in the secretion 
of bile or urine; or, in the latter case, the presence of some of the 
ingredients of the blood in the secretion. Or the disturbance of the 
function of the part, the Icesa partis fundio, may evince itself in an 
alteration or perversion of its automatic movements, as, in vomiting 
from inflammation of the stomach, and in constipation or diarrhoea, 
according to the tissue involved, in inflammation of the bowels. 

It must, however, be remembered, that, in the case of several 
organs, the integrity of the whole of which is not essential to the due 
performance of their functions, those functions may be carried on 
notwithstanding the inflammation of a considerable portion. Thus 
there may be, and not unfrequently is, considerable inflammation of 
the lungs without any perceptible embarrassment of the breathing, 
especially when the whole quantity of blood is reduced by long-con- 
tinued disease, and therefore the quantity requiring to be arterialized 



QS SECONDARY AND SY 31 PATHETIC. 

in tile lungs is diminished. So also there may be inflammation of a 
portion of the liver whilst the secretion of bile is actively carried on 
by the part which remains free from disease. 

II. Again, we may have symptoms showing themselves in parts 
distinct from that which is the seat of the disease. 

Of these, one class may be termed secondary, as when the functions 
of one organ are impaired by inflammation of another. Thus the func- 
tions of the brain may be disturbed by inflammation of the bronchi, 
the lungs, the liver, or the kidneys, owing to the depuration of the 
blood by the affected organ being checked or arrested. The liver is 
often gorged and its secretion diminished in extensive inflammation 
of the lungs or bronchi. The secretion from the kidneys is greatly 
altered in inflammation of the liver, and it is probable that the pun- 
gent heat observed in pneumonia is a phenomenon of the same 
description. 

But perhaps the greater number of the symptoms show themselves 
at a distance from the seat of the inflammation, and are divided 
by Dr. Alison into sympathetic sensations and sympathetic actions. 
They are in all probability, the latter more particularly, the result of 
a sensation or action excited at the extremity of the reflected nerve 
by irritation of the incident one. 

Of the first kind are the pain along the spine of the back, or in 
the extremities, accompanying inflammation of the brain; pain 
around the trunk, arising from inflammation of the spinal chord ; 
pain in the light shoulder, from inflammation of the liver ; pain across 
the epigastrium, from inflammation of the kidneys; pain down the 
course of various nerves, from the pressure of an aneurism ; pain at 
the extremity of the urethra, from irritation of the lining membrane 
of the bladder. 

Of the sympathetic actions are the vomiting which attends inflam- 
mation of the brain, liver, kidneys, or uterus, and in some measure 
that which is excited by inflammation of the stomach itself, since in 
the latter case as well as the former the action of the diaphragm and 
abdominal muscles is sympathetic, being an action in the part sup- 
plied by the reflected motor nerves, excited by irritation at the 
extremity of the incident nerve. Again, in inflammation of the 
Schneiderian membrane there is sneezing; and of the lining mem- 
brane of the larynx and bronchi cough; of the colon tenesmus, of 
the bladder, stranguary or incontinence of urine. 

III. Of the general and febrile signs of inflammation we have, in 
the first place, the inflammatory fever already described. 

Of the general symptoms of inflammation, as well as of all dis- 
eases, there is none more important than the pulse, which, rightly 
interpreted, will afford great assistance, not only to diagnosis in the 
more ordinary sense of the term, but also, towards estimating the 
general condition and powers of the patient; often of more import- 
ance as a guide to our treatment than the detection of any special 
local disease. In order, however, to render the examination of the 
pulse available for these purposes, we must have tolerably clear 
notions concerning the conditions requisite for the production of a 
healthy pulse. 



FEBRILE AND GENERAL SIGNS — THE PULSE. 69 

T^e must have (1) a healthy condition of the heart itself, which is 
the first moving power of the circulation ; (2,) a healthy condition of 
the orifice of the aorta, including its valves, and, of the large arteries ; 
(3,) there must be a free current of the blood through the capillaries 
and veins to the right side of the heart ; (4,) a free passage through 
the pulmonic circulation ; (5,) a due supply of nervous influence. 

(1.) By a healthy condition of the heart is meant that it is both 
structurally and functionally healthy, and that it receives a due 
supply of healthy blood. The heart may be deranged as a piece of 
mechanism, and a corresponding alteration in the force and re- 
gularity of its action will ensue ; thus its muscular walls may be too 
thick and strong, which, if there be no obstruction, will give a cor- 
responding force to the impulse as felt by the finger upon the radial 
artery, and the pulse will be hard or very full, but generally the 
former, according as the resistance of the coats of the artery is in- 
creased or diminished. The ventricle may, however, upon the other 
hand, be thin, or feeble from degeneration, and in this case, the pulse 
will be feeble and small, from the small jet thrown into the artery 
at each systole; and as a necessary consequence, the ventricle not 
nearly emptying itself, it will be continually excited to contract by 
the constant presence of blood in its cavity, and therefore the num- 
ber will be increased, or, in other words, the pulse will be rapid as 
well as small and feeble. A very feeble state of the ventricular 
parietes may also, by causing delay in the circulation, give rise to 
irregular or intermittent pulse, in the manner to be presently noticed. 
Again, as a mechanical condition, the mitral valve may be imperfect, 
in which case, the blood regurgitating into the auricle, the quantity 
thrown into the aorta must be diminished, and the pulse will be 
small ; or owing to the left ventricle not receiving a regular supply 
of its natural stimulus, the blood, its contractions, and consequently 
the pulse will be irregular. It may here be well to observe that, in- 
dependently of lesions of innervation, the chief, if not the only cause 
of intermittent pulse is a want of a due supply of blood to the ven- 
tricle: this may happen in two ways — either the current flowing 
into it may be considerably diminished, as in the case of a narrowed 
mitral orifice, or the cavity of the ventricle may have become en- 
larged by dilatation, and the quantity of blood required to excite 
regular contraction increased, in which case any obstruction tergal 
to the ventricle, or diminution in the activity of the circulation will 
induce intermission. 

(2.) Passing from the left ventricle to the orifice of the aorta we 
observe, that if this orifice be narrowed, the jet into the aorta must be 
diminished, and therefore the pulse small in comparison with the 
impulse of the heart. If, on the other hand, the valves of the aorta 
be imperfect, we may have a sufficient quantity of blood thrown into 
that vessel with each contraction of the ventricle, but, a portion of it 
regurgitating by the elasticity of the artery, the current of the blood 
will not be continuous, and, therefore, although the pulse may at first 
be felt sharp and full, it immediately subsides, conveying to the finger 
the impression of a splash, with a recoil, rather than an undulating 



70 REQUISITES FOR HEALTHY PULSE. 

current passing underneath it; this is what has been termed the 
"splashing" or "water-hammer" pulse. 

There is another character of pulse which is sometimes imparted 
to it bj disease about the aortic orifice, namely, the thrill. This may 
be felt when the current has been split or disturbed by anything pro- 
jecting into it or drawn across it, or when there is a warty excrescence 
upon one of the semilunar valves ; or when its free margin has become 
tense, and its curtain perforated. This thrill at the radial artery is 
excited by the same cause as the so-called musical murmur over the 
orifice of the aorta, and may be accompanied by it. As, however, 
the thrill may be produced by nervous excitement, an anaemic condi- 
tion, and other causes, it must not be regarded as pathognomonic, 
but merely as calling for careful investigation of the condition of the 
heart. 

In order, however, that the current of blood may be well sustained 
and uniform, instead of splashing and jerking, we must have not only 
the aortic valves or point oVappui perfect, but the elastic force of the 
large arteries which act upon it must be perfect likewise, and there- 
fore when this is greatly impaired, as it not uncommonly is, we shall 
have a splash in the pulse not unlike that produced by defective 
valves. 

The character of the pulse at the wrist is again materially influ- 
enced by the condition of the sj^stemic arteries generally, of which 
the radial, in the ordinary mode of examination, may be taken as the 
representative. If the contractility of the artery be diminished the 
pulse will be soft, and if it be increased the pulse will be hard. 

It may be as well here to remark that, assuming the valves and 
large arteries to be healthy, the character of the pulse at the wrist is 
determined by the force of the ventricular systole and the contrac- 
tility of the radial artery: thus, if the heart be acting with increased 
force, the pulse at the wrist will become fuller ; but if to this condi- 
tion there be added increased contractility of the arteries, which 
appears to be the case in active inflammation of most organs, we 
have the pulse increased in hardness as well as fulness ; if again, as 
sometimes happens, inflammation depresses the action of the heart, 
as appears to be the case when it affects structures in the neighbour- 
hood of the solar plexus, the injecting force being small, but the 
inflammatory contractility of the artery remaining, we have the small 
hard, thready, or wiry pulse. 

There is another state of the pulse at the wrist which deserves 
special notice, as it is apt to be confounded with the hard pulse of 
inflammation, and that is, an increased thickness or rigidity of the 
artery depending upon chronic change in the coats of the vessels 
— the effect commonly of advanced age, diseased viscera, intem- 
perance, or hard labour. This gives to the pulse an appearance of 
hardness or incompressibility which is not real, since by moderate 
pressure the artery may be emptied of its contents, although it may 
itself be still felt like a smooth, or sometimes rather knotted, rolling 
cord under the finger. Under such circumstances the artery will 
generally be tortuous ; this tortuosity varying with each stroke of 



CIKCUM STANCES WHICH AFFECT THE PULSE 71 

the heart gives a movement to the artery, which is probably what it 
has been proposed to describe by the term "locomotive pulse." 

(3.) We come next to the extreme or capillary circulation. It is 
evident that the character of the pulse at the wrist must be influenced 
by any obstacle to the circulation beyond it, or more removed from 
the heart, as certainly, though perhaps not so directly and obviously, 
as by one nearer to the centre of circulation. Consequently, when 
there is delav in the transit of blood through the extreme circulation, 
as in blood-diseases and fevers, where it is obstructed by the dimin- 
ished affinity between the blood and the tissues; or where there is 
mechanical obstruction to the return of the blood through the veins, 
the pulse will be rather sharp and soft, from the ready dilitation of 
the artery, and will generally have a slight recoil or back stroke, 
often observed in fevers. But, when this obstruction has existed for 
some time, the circulation will become languid, from the loss of the 
natural stimulus in the extreme circulation, and the pulse will become 
very feeble. 

Obstructed venous circulation will, as has just been shown, pro- 
duce changes in the pulse similar to those arising from capillary 
obstruction from other causes; and we shall have under such cir- 
cumstances the pulse at first rather sharp, and with a slight back 
stroke, and becoming, as the disease advances, more and more feeble, 
especially in comparison with the impulse of the heart, such impulse 
being not unfrequently excessive, owing to the distended condition of 
the right ventricle, which is very generally associated with venous 
congestion. It must be borne in mind, too, that the character of the 
pulse, especially as regards its regularity, is often modified by the 
nature of the disease producing the congestion, as in the instance of 
valvular disease of the heart. 

(4.) We come next to the right side of the heart and pulmonic 
circulation, obstruction in any part of which will produce effects 
upon the systemic circulation, and consequently upon the pulse, 
similar to those referred to venous congestion, but will also, by more 
directly influencing the supply of blood to the left side of the heart, 
tend to cause irregularities in the pulse to be presently noticed. 

It should be observed, also, that by obstructing pulmonic circula- 
tion we do not mean only mechanical obstruction, but also whatever 
interferes with the free approximation of the blood to the air in the 
pulmonary cells, and consequently impedes the action of the mutual 
affinity between them, which is one of the moving powers of that 
system. 

Obstructed pulmonic circulation also interferes with the return of 
the blood to the left side of the heart, and therefore influences the 
pulse as regards regularity as much as does narrowness of the left 
auriculo-ventricular orifice; thus sudden effusion, or dyspnoea, from 
any cause, as dilated cells, or chronic bronchitis, will render the 
pulse either very small or intermittent, the former generally if the 
left ventricle be not above the ordinary capacity, but if it have been 
previously dilated, the diminished supply of blood will then cause 
irregularity or intermission. t 



72 NERVOUS INFLUENCE ON THE PULSE. 

Besides the due supply of blood in point of quantity, the action of 
the heart and arteries, and consequently the character of the pulse, 
is materially influenced by its quality, although it is by no means 
certain whether this influence be exercised directly or through the 
medium of the nervous system. Thus anaemic blood or blood 
deficient in red corpuscles, causes a hurried action of the heart, and 
is generally associated with a diminished contractility of the arteries, 
giving to the pulse a sharpness, but at the same time want of per- 
sistance, closely resembling the splashing pulse of defective aortic 
valves. Blood also which is inquinated by disease of the depurating 
organs may act directly as an excitant to the heart; or indirectly as 
a sedative, by producing a tendency to coma through the nervous 
system. 

(5.) Another condition requisite to the regular action of the heart 
is a due supply of nervous influence, and, although that supply is 
derived mainly from the ganglionic system, yet we know from 
experiment, and from the phenomena of disease, that lesion of the 
brain and upper part of the spinal chord will materially affect the 
action of the heart, generally in the way of depressing it; and that, 
when this injury takes place very suddenly, suspension of the heart's 
action, and consequent death from syncope may ensue. In more 
chronic cases, however, disease about the medulla oblongata, and 
cervical portion of the medulla spinalis, will generally be attended 
by a slow, or intermittent pulse; and it is probably on this account 
that dyspepsia, and other diseases associated with irritation above 
the extremities of nerves proceeding from that part of the brain and 
spinal chord, are often attended with irregular or intermittent pulse. 

We have already alluded to several circumstances which affect the 
rapidity of the pulse, though but little has been said of quickness or 
slowness as distinct characters. The standard frequency of the pulse 
in the adult male may be stated as 72 ; in the female, somewhat more : 
in infancy and childhood the pulse is more frequent, being about 120 
for a child of one year old, and about 100 for a child of seven years; 
in advanced life, the frequency of the pulse generally diminishes. 
There may, however, be great difference in the frequency in different 
individuals without any evidence of disease ; thus, some persons have 
habitually a pulse of 90, or even 100; whereas others who have 
attained to a great age, have been known for many years before 
death to have had a pulse as low as 40, or even less, and to have 
been in otherwise good health. The above numbers are supposed to 
be observed in the sitting posture, as the frequency of the pulse 
varies in different positions of the body. Thus, if the pulse be 64 in 
a minute in the recumbent posture, it will be about 74 in the erect ; 
the number when the patient is sitting being nearly a mean between 
the two : the difference between the recumbent and erect pulse increases 
with the frequency, and may be stated generally at about 10 per cent, 
of the recumbent pulse. This rule is, however, liable to great excep- 
tions in disease, and, barring organic disease of the organs of circula- 
tion, it may be stated generally, that the difference is the greatest in 
cases of extreme debility. Dr. Graves has given the following results of 



.. FREQUENCY OF THE PULSE. 73 

a great number of observations made in different diseases, from which, 
however, hypertrophy and dilatation of the heart were excepted : — 

(1.) The greatest difference occurs in patients labonring under fever, 
or in a debilitated state in consequence of fever or any other cause. 
It may amount to 30, 40, or even 50, between the horizontal and erect 
postures. 

(2.) This difference decreases after the first quarter of an hour in 
most cases, but always remains considerable, as long as the same 
position is observed. 

(3.) In persons not much debilitated, this difference is much less 
than that stated above, and often does not amount to much more 
than 10. 

(4.) When the patient lies down the pulse rapidly falls to its 
former standard. 

(5.) In some the increase in frequency is greater between the hori- 
zontal and sitting posture than between the latter and the erect, 
while in others the contrary takes place ; so that, generally, the fre- 
quency in the sitting posture may be taken as a mean. 

(6.) In persons convalescent from fever or actute diseases, it is ex- 
tremely useful to ascertain the comparative frequency of pulse in the 
horizontal and the erect position.* The greater the difference, the 
greater is the debility in the patient, particularly if the pulse, on his 
lying down, does not resume its usual degree of frequency. 

In disease of the heart, however, there is often a remarkable ex- 
ception to the above rules, — the pulse maintaining the same fre- 
qency in each posture; and this is more particularly the case when 
there is great hypertrophy with dilatation. 

In order to make the foregoing remarks more directly available 
for the purposes of diagnosis, we may regard the pulse as cha- 
racterised by — 

(1.) Its force. 

(2.) Its degree of compressibility, which includes the condition 
described by the terms hard or soft. 

(3.) Its volume. 

(4.) Its distinctness; a condition which has, perhaps, not been 
sufficiently noticed by the generality of practitioners, but which, as 
may be inferred from what has been already said (p. 71), depends 
primarily upon the force and regularity of the systole of the heart; 
and, secondly, upon the free transmission of the blood, through the 
extreme circulation ; the feeble and undulating pulse, in some cases, 
and the recoiling or dicrotous pulse in others, being often indications 
of capillary obstruction. 

(5.) Its rhythm, or regularity. 

(6.) Its frequency, which will depend upon the nervous irritability 
of the heart, and the amount of its natural stimulus, to wit, the blood 
which it receives. It is increased — by nervous excitement, as mental 
emotion — by muscular exertion, which hastens the return of the 

* This applies particularly to the acceleration on rising from the recumbent position. 



74 FORCE OF FEEBLENESS. 

blood to the heart along the veins — by inflammation, which, acts 
partly in the same way, thongh partly also through the influence of 
the nerves — by obstructed circulation, which, by opposing the cur- 
rent of the blood from the heart, prevents its freely emptying itself, 
and thereby keeps it continually under the influence of the stimulus 
of distension — by debility, unless there be. perfect freedom of the 
capillary circulation — by the febrile state, in which several of the 
above conditions may be supposed to be combined. 

It may readily be conceived, that, as each of these conditions is 
independent of the others, we may have them differently combined, 
so as to produce almost endless varieties in the pulse, this is so nearly 
what occurs in practice, that it would be more than difficult to spe- 
cify every possible character of the pulse, so as to attach to each its 
diagnostic significance; we will therefore merely take, by way of 
illustration, one or two conditions, in order to point out how they 
may be interpreted, by their combination with others. 

The pulse may have considerable force — this will indicate strong 
contraction of the left ventricle, which may arise from increased 
excitement, or from hypertrophy. Now one of the most frequent 
causes of excitement of the heart is inflammation, but, associated 
with inflammation, there is generally an increase in the contractility 
of the arteries — this will render the pulse hard as well as forcible ; 
such is the general character of the pulse in inflammation, with the 
exception, that in inflammation of some tissues, as the mucous mem- 
branes, the contractility of the arteries seems but little affected, and, 
accordingly, we have a sharp, but not hard, that is to say, a com- 
pressible pulse. In other inflammations, again, affecting structures 
in the neighborhood of the solar plexus, the force of the heart's action 
is diminished, but the contractility of the artery remains, and we 
have the small and hard, that is to say the wiry pulse. 

The force of the pulse is also influenced by the condition of the 
left ventricle; if this be large, and its walls thick, we shall have a 
corresponding force and volume in the pulse ; this is often counter- 
acted by an increased thickness in the coats of the artery, giving to 
the pulse a considerable degree of hardness ; and when this state of 
the artery is far advanced, there is given to it a tortuosity, which, 
undergoing a change at each contraction of the heart, gives rise to 
the movement that has been rather whimsically described as the loco- 
motive pulse. 

The splashing pulse, another modification of the forcible and full 
pulse, is caused by hypertrophy, when the continuous current of the 
blood is not maintained, owing to regurgition through the aortic 
valves; the same thing happens, though in rather a less marked 
degree, when the elasticity of the large arterial trunks is destroyed 
by disease, or that of the whole arterial system greatly diminished 
by excessive haemorrhage. 

Smallness, or feebleness of the pulse, indicates a corresponding 
feebleness in the action of the left ventricle, and is still more charac- 
teristic when the pulse is at the same time soft, which shows that its 
smallness is not owing to any increased contractility in the artery. 



THE TONGUE. 75 

This diminished action may arise from debility of the system in 
general, or of the heart itself, or from a diminished supply of blood to 
the left ventricle, as in obstructed circulation through the lungs. It 
may also be caused by general capillary obstruction, as in blood 
diseases, the central moving power gradually failing in its action 
when the natural stimulus of the extreme circulation, — the affinity 
between the blood and tissues — is withdrawn. Preceding this feeble- 
ness of the pulse in blood diseases, there will often be a full, soft, but 
rather jerking pulse, not very dissimilar to the splashing produced 
by an increased effort of the heart to overcome the peripheral obstruc- 
tion, the contractility of the artery being at the same time less than 
in health; or, in other cases, such obstruction may cause a slight 
back stroke, which is the dicrotous pulse. 

The conditions requisite for the regularity of the pulse have been 
explained to be — a uniform current of blood to the left ventricle, 
and a due supply of nervous influence. Intermittent pulse does not 
therefore, as has sometimes been stated, necessarily indicate valvular 
disease of the heart, but some circumstance tending to interfere with 
either of the above conditions. Amongst those which impede the 
due supply of the left ventricle, may be reckoned, disease of the 
right side of the heart and pulmonary artery, disease of the lungs 
and their appendages impeding the pulmonic circulation, and disease 
of the left auriculo-ventricular orifice. Irregular or intermittent 
pulse also occurs when the muscular walls of the heart are degene- 
rated or attenuated; though probably as the result of the pulmonic 
congestion always attendant upon such a condition. When the 
pulse becomes intermittent from any of these causes, it is almost 
always at the same time very feeble or indistinct. Circumstances 
may, however, arise which may prevent the pulse becoming irregular 
notwithstanding the presence of some of the conditions just described. 
Intermittent pulse may also be the effect of disease of certain portions 
of the nervous system ; or (through the medium of the nerves) of the 
digestive organs. 

Next to the pulse, the tongue presents us with the most important, 
of the signs of general and febrile disease, as well as, in many cases, 
of affections of particular organs, though it is with the former that 
we are now more immediately concerned, since its connection with 
special diseases will be more conveniently stated when we come to 
treat of them separately. 

"The mode of protruding, of holding out, and of withdrawing the 
tongue is," as Dr. Copland observes, "always deserving of attention. 
It is protruded with difficulty in comatose and paraly tic cases, and 
also when there is great prostration from whatever cause arising. It 
may sometimes not be protruded at all, either from insensibility to 
the command to do so, or from inability to comply with it : this also 
indicates loss of sensorial or muscular power. The tongue may 
appear increased or diminished in size in different diseases, inde- 
pendently of local disease of that organ itself; it is enlarged as in 
complication of angina, of scarlet fever, small-pox, of hysteria, epi- 
lepsy, syphilis, and as a consequence of mercurial action, or of 



76 SIGNS OF DISEASE. 

poisons."* A broad, flabby tongue, indented by the teeth, or a 
fissured and sulcated, as well as enlarged one, is seen in mercurial 
action, and also in disorder of the digestive organs with debility, and 
in connection with hepatic derangement. A tumid and livid tongue 
is indicative of disease in the heart or lungs obstructing the pulmonic 
circulation, and interfering with the aeration of the blood ; if it be, 
moreover, covered with a cream-like mucus, it shows that there is at 
the same time irritation of the mucous membranes. 

The tongue appears small, often narrow and pointed in low fevers, 
and in gastric irritation; also in irritation of the membranes of the 
brain, especially if it be at the same time red at the tip and edges. 

The moisture of the tongue is produced mainly by the salivary 
secretion poured into the mouth, to which may be added the exha- 
lations from the mucous lining of the mouth and fauces ; the presence 
or absence of this moisture is of great significance in regard to the 
state of the secretions, of the vital powers, and of the circulation. 
As a general rule, moisture is a sign of the absence of severe fever. 
Excessive moisture is symptomatic of debility, especially if attended 
with softness, and indicates the use of tonics, or to say the least, the 
avoidance of lowering measures. Dryness of the tongue belongs to 
that diminution of the secretions which accompanies severe and dan- 
gerous fever, though in estimating this sign, we must not forget that 
the tongue is sometimes rendered dry by the patient sleeping or 
lying with the mouth open. 

Every departure of the color of the tongue from its natural hue 
deserves attention. A pale tongue belongs to an anaemic or spanaemic 
condition of the blood, a very red one attends inflammation of the 
throat and fauces, and eruptive fevers; redness at the tip and edges, 
gastric inflammation or irritation; a very red glazed tongue shows a 
still greater degree of intestinal irritation, probably with ulceration, 
and is a dangerous symptom. The brown or black coat upon the 
tongue is, again, a sign of the very lowest form of fevers, with failure 
of the vital powers. The livid tongue we have already alluded to 
as showing defective decarbonization of the blood. 

The white tongue should be distinguished from the pale tongue, 
the paleness being, as it were, the complexion of the organ itself, 
whereas the whiteness appears as if produced by a pigment upon it ; 
this whiteness belongs to the early periods of active fever. A 
clammy, yellowish, or creamy coating upon the tongue, indicates 
fever with considerable gastric derangement; and in more advanced 
stages of such affections the organ becomes loaded, the coat being 
thicker, and the color deeper. 

The furred tongue is among the most important of the indications 
of the febrile state ; it has been well compared by Dr. Copland to the 
pile on the surface of cotton velvets; the origin of the fur is by no 
means clearly understood, it is, perhaps, referable to marked develop- 
ment, or it may be erection, as in the case of erectile tissue, of the 
papillae, under the irritation of the gastro-intestinal mucous mem- 

* Copland, Dictionary of Practical Medicine : Art. Symptomatology. 



THE TONGUE. 77 

brane which attends most febrile and inflammatory disease, especially 
inflammation of the parenchymatous viscera, of the mucous surfaces, 
and the encephalon, as well as exanthematous and typhoid fevers. 
Associated with this fur, may be more or less of the white or creamy, 
or drab-colored load just alluded to, and the elongated papillae pro- 
truding themselves through this coat often gives to the tongue a 
slimy, spotted, or as it is sometimes called "limaceous" appearance. 
This appearance is peculiarly common in many of the febrile dis- 
eases of children, who are especially prone to gastric derangements. 
When after the above conditions, the tongue becomes red and clean, 
without subsidence of the fever, and still more if it become dry and 
glazed, it is an unfavorable sign, indicative of feeble power with 
much gastric irritation ; and if it be dry and dark, the load assuming 
the form of a brown or black crusty it indicates a state of the lowest 
typhus, with suppression, or great disorder of the secretions, and 
contamination of the blood. With a slight fur, again, there may be 
here and there patches denuded of epithelium, a condition which 
belongs, perhaps, more to chronic or non-febrile disease of the 
digestive organs, or to uterine irritation; and an aphthous state of 
the tongue in adults shows failing vitality, and generally pretty 
closely precedes the fatal termination of phthisis and other wasting 
diseases. The only diseases in which the temperature of the tongue 
is materially affected is the malignant cholera, in the severe forms 
of which disease it is often cold from the commencement. 

Before quitting the subject of the tongue, we may remark, that 
though the appearance of the tongue is always more or less affected 
by disease in the stomach and small intestines, it may remain quite 
natural in appearance, notwithstanding severe disease beyond the 
ileo-caecal valve. 

There are again two other circumstances which are of great import- 
ance in estimating the general condition of the system, and these are 
thirst and hunger: the former of which is generally excessive, and 
the latter abolished during the febrile state. 

To appreciate the value of thirst as a symptom we should have 
some definite ideas of the cause of thirst in health and disease. It 
is commonly stated that the sense of thirst indicates a deficiency of 
fluid in the body ; this is to a certain extent true in health, that is to 
say, the sense of thirst indicates a condition in which more water is 
.required for its two important physiological purposes, namely (1) 
the facilitating the circulation of the blood by increasing its fluidity, 
and (2) the clearing or washing of the blood from those impurities 
which are destined to be carried out of the system by the liquid 
secretions, and the course of the water in fulfilling this office has 
been already described (p. 35), and as in health the effect is produced 
by the taking of water into the stomach, the final cause of thirst is 
no doubt to induce the ingestion of fluid ; but in order to allay the 
sensation of thirst, the water must not only be taken into the 
alimentary canal, and there absorbed into the blood, but it must 
also pass out of the system by the proper channels, carrying with it 
those matters which it is intended to eliminate; and if this be not 



78 THIKSTS — HUNGER — APPETITE. 

effected, the sense of thirst may continue : thus not only is thirst 
excessive in Asiatic cholera, in which the blood is nearly drained of 
its water, but also in dropsy from disease of the kidneys, in which 
the patient is sometimes, as it were, overwhelmed with the quantity 
of fluid in the system, the blood being at the same time " watery" in 
the extreme ; so that, looking merely to the blood, not only may 
thirst be induced by an absolute defect of water in the blood, but 
also by the presence in that fluid of those substances which the water 
ought to eliminate ; and it is not improbable that the urgent thirst in 
cholera may arise as much from the latter cause as from the former. 

Again, though the cause of the healthy thirst may be in the blood, 
the seat of the sensation is in the fauces, and that sensation is per- 
ceived through the instrumentality of the nerves ; it may therefore 
happen that a disordered state of the part which is the seat of the 
sensation, or even of the brain which receives that sensation, will 
produce thirst, as well as the condition of the blood by which it 
ought to be excited in health; and (by a parity of reasoning) it may 
arise by disorder or irritation of other parts, which derive their 
nervous supply from the same source, as in disease or irritation of 
the gastro-intestinal mucous membrane. 

Thirst, then, may be regarded as a sign (1) of absolute defect of 
liquid in the blood; (2,) of excess in the blood of those substances 
which the water ought to remove; (3,) of irritation in the gastro- 
intestinal membrane ; (4,) of disordered innervation. 

The final cause of hunger is to induce the ingestion of alimentary 
substances, whereby the continual waste of the system may be 
repaired; the seat of the sensation of hunger seems to be in the 
stomach, and the most satisfactory explanation of that cause is, 
that there is at the same time a determination of blood to the mucous 
surface of that organ, and an increased excitability of the sentient 
extremities of the nerves with which it is so freely supplied, or 
whether either of the last conditions is to be regarded as cause of 
the other, it may be hard to determine. Healthy appetite for food, 
then, implies a healthy condition of the system generally, more par- 
ticularly of the functions of nutrition and circulation; a healthy 
state of the nervous system, and of the stomach itself; but, besides 
this, in order that the appetite may recur at proper intervals, we 
must have the food which is taken into the stomach digested and 
absorbed, and the refuse matter removed from the small intestines: 
a healthy state of all the digestive organs is therefore necessary. 

In febrile, diseases there is loss of appetite, especially at the com- 
mencement ; this, however, does not appear to arise from any great 
diminution in the waste of the tissues, since this goes on apparently 
with nearly as much activity as in health ; the reason of the dimin- 
ished appetite is, perhaps, rather to be found in the derangement of 
the circulation and innervation, and in the disordered secretion. After 
the febrile state has passed off, there will often be an excessive appetite, 
arising from the increased requirements of the system to repair the 
waste which has been going on during its suspension. In many 
diseases of the brain, again, we have loss of appetite from loss of 



SIGNS OF DISEASE. 79 

proper sensation, or due appreciation by the brain of the condition 
of the stomach ; but from disease in the same organ we may also 
have an increased or morbid appetite from irritation in the sentient 
organ, producing the sensation without its proper cause ; there is in 
this case a subjective instead of an objective hunger. Appetite, again, 
may be excessive from an erythism, or irritation of the stomach 
itself, though if this proceed to inflammation it will produce loss of 
appetite and sickness. Excessive appetite will also sometimes occur 
in wasting diseases, as well as in those in which the products of 
digestion do not find their way into the system, as in disease of the 
mesenteric glands obstructing the passage of the chyle through the 
lacteals. Loss of appetite may also arise from languid circulation 
and torpor of the system generally, through want of exercise, and 
confinement in an impure air. The influence of the nervous system 
upon the appetite need scarce further proof than the effect of mental 
emotion; anxiety and depression, as from distressing intelligence, 
often suppressing it altogether. 

Besides the information to be obtained from the sources just in- 
dicated, we may learn much by attending to a variety of circum- 
stances in the general aspect and condition of the patient, which, 
though at first sight trifling minutiae, constitute what we would 
venture to term the physiognomy of disease, and which, though they 
may not furnish us with certain evidence of any particular lesion, 
often act as it were as the finger-posts to our investigations, and 
point towards the disorder we are to expect, or the particular organ 
or region of the body to which we should direct our inquiries. 

The attitude of the patient and the expression of his countenance 
are among the first things which deserve our attention. The former 
may indicate extreme weakness or prostration, as shown by a per- 
fectly supine position, the extended legs, the arms lying powerlessly 
by the side of the body, and the head either helplessly thrown back 
upon the pillow, or gravitating rather than turned to one side or the 
other. Again, the patient may be lying on the back, with the knees 
slightly drawn up, and continually retaining this position, from a 
desire to remove the pressure of the abdominal muscles or bed- 
clothes, and at once suggesting to the experienced observer an appre- 
hension of inflammation of a portion of the peritoneum. With the 
supineness of prostration there may also be restlessness, and the 
" disjecta membra" of rapid exhaustion from haemorrhages, or other 
profuse discharges, as in cholera. There may, again, be inability to 
lie on one side, as in effusion into the pleural cavity on the opposite 
one, or the patient may lie with difficulty or pain on one side, as in 
the early stages of pleurisy and some affections of the heart. Again, 
there may be inability to lie clown at all, constituting what is tech- 
nically termed orthopnoea, the result of asthma, sometimes of effusion, 
and sometimes of organic disease of the heart, of extensive and severe 
bronchitis, pneumonia, or oedema of the lungs. Often too, when the 
orthopnoea is the result of inflammation of the pericardium or of the 
diaphragmatic pleura, the patient sits or crouches forward so as to 
prevent the movements of the diaphragm, which, in such cases, 



80 GAIT — EXPRESSION. 

aggravate his distress. These and many other peculiarities of posi- 
tion in lying or sitting it will be our duty to notice more particularly 
in reference to special diseases, and they are here introduced only as 
instances of the effect of disease upon the position of the patient. 

It is not, however, only in lying or sitting that we should carefully 
watch the attitude of the patient. When able to stand or walk there 
may be a dragging or halting of one leg, indicative of incipient 
paralysis, or the gait may be staggering and nnsteady, from cerebral 
congestion oppressing the nervous power, softening or other structural 
change impairing it, or intoxication suspending it. There may, too, 
be a hurriedness about every movement, indicating an excessive 
nervous irritability, or an irregularity and unsteadiness, more espe- 
cially of the hands and arms, which accompany the first beginning of 
chorea. The gait, too, may be stooping, with the back raised, and 
the chest depressed, and the head thrown forwards, in disease of the 
heart or large arteries, especially aoric aneurism. The wasted victim 
of organic disease of the stomach or other abdominal viscera has a 
stooping gait, often with a hand placed upon the epigastrium, con- 
trasting with the well-fed citizen who has reached the middle period 
of life, with his digestive powers as yet unimpaired, and who walks 
erect with his hands crossed upon the sacrum as a sort of counterpoise 
to the somewhat redundant weight in front. 

The expression of the countenance is no less available as a guide 
to our researches. Like the position of the body, it may indicate 
simple prostration, as in the advanced stage of low fever, when the 
countenance is shrunken and collapsed, and at the same time apathetic 
and inexpressive; or it may be shrunken and contracted, but with 
the compressed lips and retracted angles of the mouth, constituting 
the risus sardonicus, indicative of acute inflammation in the neigh- 
bourhood of the diaphragm. 

The expression of pain may accompany not only acute inflamma- 
tory diseases, but those also in which there is difficulty of respiration, 
disturbed or irregular action of the heart, soreness of different parts, 
and severe neuralgic pain. Anxiety belongs not only to some forms 
of mania, but also to dyspepsia and its consequence — hypochondriasis, 
and to other disorders of nutrition, amongst which may be reckoned 
diabetes, and to most chronic diseases, especially those of the ab- 
dominal viscera. An expression of terror is often impressed on the 
features by haemorrhages and other exhausting discharges (in cholera 
the countenance expresses terror rather than pain), by some obscure 
forms of mania, and above all, by delirium tremens. Eage belongs 
more particularly to violent delirium whether in the form of mania 
or phrenitis. 

There may, on the other hand, be a want of all expression, in 
idiotcy and general paralysis, and sometimes in chorea. There may 
be an almost incessant hilarity, in some forms of chronic disease of 
the brain. The countenance, again, may be heavy, dull, or oppressed, 
in cerebral congestion, and there is sometimes a bashful downcast 
look in the hysterical female ; and this, with the averted eye, belongs 
equally to those of either sex who have impaired their nervous 



SIGNS OF DISEASE. 81 

power, and with, it, often, their physical and moral courage, by self- 
abuse. 

The colour or tint of the countenance is much affected by disease. 
It may be rendered pale by the want of red corpuscles in the blood; 
this paleness may show itself in somewhat different characters, as 
in the dingy whiteness of malignant disease, in the waxen hue of 
amenorrhoea, and in the white and puffy countenance of dropsy from 
disease of the kidneys. It may be coloured also by retained secretion. 
Thus, when there is excess of bile in the blood, the face, as well as 
the general surface of the body, becomes yellow, and so do the con- 
junctivae. The retention of the colourless urea, or uric acid, does not 
tinge the blood, or through it, the countenance. The deep blue tint 
imparted to the corpuscles by carbonic acid shows itself in the coun- 
tenance when the elimination from the blood of that gas is interfered 
with; whether it be by difficulty of access of air, as in choking, or 
suffocation, — or by other affections tending to apncea from obstructed 
pulmonic circulation, as disease of the lungs or heart, — a mixture of 
the blood of the two circulations, as in communications between the 
two sides of the heart, — or its stoppage by loss of fluidity, as in 
cholera. 

In the clinical investigation of disease we must not omit to cul- 
tivate another sense, which will often give us most important in- 
formation, namely the sense of smell. And though it may not be 
very easy to describe an odour, it is by no means difficult to remem- 
ber one that may be frequently presented to us. Thus the sourish 
odour from the perspiration which continually bedews the surface in 
acute rheumatism cannot easily be forgotten, and there is an odour 
not so easily recognised about the persons of those suffering from jaun- 
dice or albuminuria. A cadaveric odour, which is a most unfavour- 
able omen, hangs about those in whom the blood is, as it were, 
stagnating in the capillary vessels, as in cases of the typhus and 
exanthematous fevers, and in great venous obstructions, where the 
cadaveric changes seem, as it were, to precede the apparent death of 
the patient. Besides this there is an odour peculiar to different 
fevers, as typhus, scarlatina, and small-pox. There are, again, cha- 
racteristic odours about the breath, as the hay -like smell in diabetes, 
and the sourish smell of the breath of children with any tendency to 
gastric fever; and a smell not very different from this, which may 
be observed in adults who are affected with venous congestion of 
the liver; and a smell, it is next to impossible to describe, that is 
not, however, like the smell of alcohol, which may be detected in 
the breath of the habitual drunkard. The foetor of the breath from 
mercury, and which often precedes its more decided effects upon the 
gums, should be familiar to every practitioner, as should all the 
smells of alcohol and various other poisons which affect the breath 
as soon as they have been swallowed. The odours of many dis- 
charges, as, for instance, the urine, when there is incontinence or 
dribbling from retention, as well as various uterine discharges, should 
also immediately attract our notice, and may often suggest important 
questions, at the same time they may lead to the discovery of any 
neglect of cleanliness on the part of the attendants. 

C 



82 FATAL TERMINATIONS OF INFLAMMATION. 



VI. 

FATAL TERMINATION AND TREATMENT OF 

INFLAMMATION. 

Before proceeding to consider the treatment of inflammation it is 
desirable to have clear notions of the different modes in which it 
may prove fatal, since one of the most important indications of treat- 
ment in all diseases is to " obviate the tendency to death." It may 
be observed, however, that the fatal termination of inflammation is 
scarcely ever the necessary and inevitable consequence of the inflam- 
mation as such, but is dependent upon its intensity, or the extent 
and degree of its results, and not upon the mere fact of its presence. 

Inflammation may sometimes prove fatal in its very commence- 
ment, by its depressing effect upon the moving powers of the circula- 
tion, "before any structural alteration has taken place in the inflamed 
part. The tendency to this result is indicated by the rapidly-in- 
creasing feebleness of the pulse and failure of the heart's action, cold 
extremities, shrunken features, and clammy perspiration ; the powers 
of voluntary motion not being for the most part depressed in the 
same proportion, and the intellect remaining unimpaired. The best 
illustration of this fatal effect is to be found in inflammation of the 
peritoneum, especially when it attacks the part investing the stomach 
or neighbouring viscera. Inflammations of other serous membranes, 
as the pleura or pericardium, may sometimes threaten the same con- 
sequences, especially when that inflammation is excited by any sudden 
mischief, the result either of disease or accident. Inflammation of 
the mucous membrane of the intestines is also attended with more or 
less of the same depressing effect upon the heart's action, and the 
same thing may be seen, though not so frequently, as one of the 
earliest consequences of inflammation of the large joints and more 
important viscera ; thus, we may have death by syncope as an early 
and direct result of inflammation, before it can have produced such 
structural change in a vital organ as to impede any function necessary 
to the continuance of life, and in a manner different from that which 
would ensue from such impediment. 

Death in a mode not far differing from that by syncope, that is to 
say, by a more gradual failure of the moving powers of the circula- 
tion — death from sinking, as it is commonly termed — may take place 
at any period of severe and extensive inflammations. 

Inflammation may be fatal by its arresting the functions of some 
vital part, either directly, or by means of the effusions consequent 
upon it. 

Inflammation may suspend the functions of a part by its mere 
presence in great intensity, independently of any structural altera- 
tion of the part. Of this we have an instance in the arrest of the 
peristaltic movements which attends the commencement of enteritis; 
and it is, probably, in this way that we are to account for the convul- 



F A T A L ' T E R M I N A T I X S OF INFLAMMATION. 83 

sions, delirium, and paralysis, or stupor, which sometimes attend the 
first onset of inflammation of the brain. 

Inflammation may cause death by the serous effusion, which is its 
first result, obstructing the functions of some vital part, as in inflam- 
matory effusion of serum upon the surface or into the ventricles of 
the brain, causing death by coma ; effusion into the submucous areolar 
tissue of the glottis, causing death by strangulation and apnoea ; rapid 
effusion into the air-cells of the lungs, or into the pleura, producing 
death by apnoea — into the pericardium, causing death by failure of 
the heart's action, or syncope. 

A fatal result from the increase of the proper secretion of a part, 
arising from the effusion of serum, may be seen in some cases of 
inflammation of the bronchial membrane, though this arises from 
puriform, as frequently as from serous inflammation, or even 
more so. 

The plastic effusion from inflammation may prove fatal by the 
mechanical obstruction which the fibrinous lymph opposes to the 
performance of some functions essential to life ; as, when respiration 
is obstructed by the lymph effused upon the mucous lining of the 
larynx or trachea in acute inflammation of those passages, or more 
slowly by the thickening of the membrane by the deposit of lymph 
in the submucous areolar tissue — or the action of the intestinal canal 
arrested by the lymph effused on the surface of the inflamed peri- 
toneum; or the passage of its contents stopped by the thickening 
and contraction resulting from the effusion of plastic lymph into the 
submucous tissue. In the same way the action of the heart may be 
greatly obstructed, if not altogether arrested, by adhesive inflamma- 
tion of the pericardium. 

Death may also take place from the mechanical effects of puriform 
effusion in obstructing the functions of some vital organ, in the same 
manner as does the effusion of serum. Thus we may have death by 
coma from puriform effusion on the surface of the brain ; death by 
apnoea from deposits of puriform matter producing pressure upon the 
larynx, trachea, or bronchi, or from great puriform effusion into the 
air-passages, or into one or both pleura. 

But there are other and more direct ways in which death may 
ensue from suppuration: 1, by the exhaustion resulting from the con- 
tinual drain of a large discharge of puriform matter, diminishing the 
quantity of blood and rendering it poor, so that the action of the 
heart fails for want of its accustomed stimulus, and death takes place 
by a gradual syncope; 2, when the pus finds its way into the circula- 
tion, and acts as a poison in the system, as in the case of inflammation 
of the lining membrane of a vein, the accompanying fever being in 
such cases attended with a feeble action of the heart and, derangement 
of the nervous system; death, when it does take place, coming on 
more in the way of syncope, though sometimes with a tendency to 
coma. 

As ulceration is almost constantly accompanied by suppuration, 
which may be very great, it follows that when the former is very 
extensive we may have death from the discharge of pus leading 



84 TREATMENT OF INFLAMMATION. 

to exhaustion, and also death from puriform infection as above 
described. Death may also result from the secondary effects of the 
injury inflicted by the ulceration, as when the tunics of any portion 
of the alimentary canal are perforated by an ulcer, and the escape of 
the contents gives rise to sudden inflammation of the peritoneum, 
which is often attended by collapse, terminating in death by syncope, 
or the same fatal termination may be induced by haemorrhage, owing 
to a considerable vessel being laid open in the progress of ulceration. 

The leading objects which we should place before our minds in the 
treatment of inflammation are : — 

I. To obviate the exciting cause of inflammation when we can 
ascertain that cause, and when it is one which we are able to control. 

II. To prevent and remove all other circumstances which may 
tend to excite or keep up the inflammatory action. 

III. To induce, if possible, the resolution of the inflammation. 

IV. When we perceive that one of the results of inflammation, 
already described, (pp. 48, 49,) must ensue to lead that process to its 
most favorable termination. 

I. It not uncommonly happens in surgical practice, that inflamma- 
tion has been excited, and is still kept up by some cause which we 
can remove, as when there is a splinter in the hand, or inflamma- 
tion has been excited by the extremities of a .fractured bone, or the 
mucous membrane of the bladder is irritated and inflamed by a 
calculus, in which cases the splinter may be excised, or the fracture 
reduced, or the stone removed ; but in medical practice (and par- 
ticularly when we have to deal with acute inflammation) it oftener 
happens that the cause of the disease has ceased to act, and we have 
to deal only with the inflammation which remains as its effect, or if 
there be any internal cause still at work, it is but seldom that we are 
able to get at it, as in the case of inflammation of the peritoneum 
from a perforating ulcer of the intestine, or of the appendix coeci 
from a foreign body lodged in its canal ; though there may, indeed, 
be an irritating substance in the stomach or bowels which we may 
be able to neutralize or remove. 

In many inflammations of a more chronic character there may be 
causes still in operation ; as exposure of the lining membrane of the 
air passages to irritating gases or pulverized substances; or inflam- 
mation of the mucous membrane of the alimentary canal may be 
kept up by stimulating drinks, or irritating articles of food ; and in 
any such case we may often be enabled to put an end to the cause, 
and so bring about the subsidence or resolution of the inflammation 

O 

to which it had given rise ; though we may not thereby remove the 
change in the condition of the part which the inflammation had 
slowly and insidiously brought about : for it is very important to 
bear in mind that there is a wide difference, both pathologically and 
in practice, between the inflammation which produces a certain 
structural change, and the derangements consequent upon that 
change ; and, perhaps, one difficulty in the treatment of chronic in- 
flammations consists in the circumstance that this structural change 



GENERAL INDICATIONS. 85 

commonly goes on pari passu with the inflammatory action which 
produces it. 

Although, however, the cause which excited the inflammation may 
have passed away, or be necessarily beyond our control, we may 
by knowing it be enabled to prevent its repetition, and gain some 
guidance as to our practice in other respects: thus we should not 
treat an inflammation of the pleura from cold in the same manner as 
one from perforation of the lung, or of the pericardium from rheu- 
matism, as one from disease of the kidneys. 

II. In order to carry out the next object, viz., the prevention and 
removal of all circumstances which may tend to keep up, or re-excite 
the inflammatory action, we have two considerations to attend to. 

1. The removal of all those circumstances which may tend to 
maintain an inflammatory action in the system at large : this is 
effected, in great measure, by what is commonly termed, the anti- 
phlogistic regimen, the object of which is to place the patient in a 
condition which most favours the spontaneous subsidence of the 
inflammation; it consists in the avoidance of whatever tends to 
excite the action of the heart or arteries, as stimulating drinks, 
animal food, muscular action, mental excitement, stimulants to the 
external senses, as light and noise : it may be summed up in the few 
words — low diet, rest, quiet. 

2. We must put out of the way, as much as possible, all those 
circumstances which may excite the afflux of blood to the particular 
part or organ inflamed ; thus, when there is inflammation of a limb, 
we keep it in such a position that the afflux of blood towards it will 
not be favoured by gravity; and if a joint is inflamed we keep it at 
rest, and on the same principle must we deal with inflammations of 
internal parts. We must endeavour to obviate the determination of 
blood towards them, and as an important means towards this end, to 
suspend, or diminish as much as possible, the performance of their 
proper functions ; or where this is impossible, to remove, as far as we 
can, all things that may tend to stimulate them. 

This principle, though important and self-evident, is not perhaps 
recognized as capable of such general application in the treatment of 
inflammations of internal parts, as it undoubtedly is ; thus, we should 
not only remove the stimulus of light from an inflamed eye, and of 
sound from an inflamed ear, but that, of all strong impressions of 
the senses, and of mental excitement from an inflamed brain. The 
mechanical excitement of speaking must be avoided when the larynx, 
air passages, and lungs are inflamed ; but the stimulation of an acutely 
inflamed bronchial membrane, by those expectorants which excite it, 
when exhaled by the lungs, must be as carefully abstained from ; and 
the steady maintenance of a uniform temperature is to be enjoined 
upon the same principle, because a want of heat, or variations of 
temperature, by calling for a greater activity in the function of res- 
piration, quickens the circulation through the lungs. Nature shows 
the necessity of suspending the functions of the stomach, when that 
organ is inflamed, by the immediate rejection of any articles of ali- 
ment that maybe taken into it; but art is not always equally cautious 



86 TREATMENT OF INFLAMMATION. 

to avoid the excitement of the peristaltic action of inflamed intestines. 
If calomel be, as is commonly supposed, a stimulant of the liver, it 
ought at least to be used with caution when that organ is inflamed; 
and the same principle ought to be applied to the use of diuretics 
when the secretion of urine is suppressed by the inflammation of 
the kidneys. 

III. The above remedies, namely, the avoidance of the exciting 
causes of inflammation, and the abstraction of those conditions which 
aggravate or keep it up, though highly important and necessary to 
be appreciated, must be regarded in the light rather of negative than 
positive agents. We come now to speak of those means which have 
a direct influence in checking the inflammation at any part, or of 
fulfilling the third indication above mentioned, namely, the inducing, 
if possible, the resolution of the inflammation. Of these means, the 
most powerful is the abstraction of blood. 

Blood-letting is of two kinds, general and topical. General bleed- 
ing is the abstraction of blood from a single vessel sufficiently large 
for the purpose, as by arteriotomy or the opening of an artery, or 
phlebotomy or venesection, i. e., opening of a vein. Topical bleeding 
is the withdrawal of blood more slowly from the smaller vessels of a 
part, for which purpose various means are employed; the more com- 
mon of these are cupping, the application of leeches, and scarifying 
or puncturing with a lancet. As regards the expediency of these 
different methods in one or the other kind of bleeding, the common 
mode of general bleeding by the opening of one of the veins at the 
bend of the arm, is undoubtedly the most convenient, as being the 
most easily applicable, and affording the greatest facilities for regu- 
lating the quantity to be abstracted, and the rapidity with which it 
is to flow. In some subjects, however, especially fat and healthy 
persons, the veins are very small, or lie so deep as to be reached with 
difficulty, in which case, a more accessible vein in some other part 
may be chosen, or arteriotomy may be performed. The objection 
to this latter operation is the difficulty that there frequently is in 
making an opening into an eligible artery large enough to allow of 
the flow of a sufficient stream of blood, and the difficulty when this 
has been done of closing the vessel so as to prevent subsequent 
haemorrhage ; it ought therefore never to be performed excepting in 
an artery upon which we are able to use permanent pressure, as the 
temporal. On the other hand, it is supposed by some practitioners 
that arteriotomy combines the effects of general and local bleeding, 
by diminishing the circulation in the part supplied by the artery, and 
at the same time withdrawing the blood quickly from the system, as 
in venesection. 

The different methods of topical bleeding are applicable to different 
circumstances. Cupping is perhaps the most efficacious and the most 
speedy ; it is also but little likely to be followed by excessive haemor- 
rhage. On the other hand, it is more painful, or at all events more 
terrifying to the patient than the application of leeches ; the blood is 
also more quickly abstracted by this method, so that it has more of 
the effect of general bleeding, and therefore is sometimes inapplicable 



TOPICAL BLEEDING. 87 

where the latter is strongly contra-indicated. In females, too, some 
weight must be given to the consideration of its leaving unsighty 
scars, where the part from which the blood is to be taken is not ordi- 
narily covered by the dress. Cupping has the further effect of a kind of 
revulsion, by drawing a considerable quantity of the blood to the part 
over which the cups are applied. The operation of dry cupping, as it 
is termed, i. e., without scarification, is emploj^ed with this inten- 
tion, and has sometimes a beneficial effect in withdrawing for a time 
a portion of blood from the pale of the circulation, in cases where we 
are fearful of abstracting it from the system altogether. 

Leeches, again, have the advantage of being readily applied, and 
are not so formidable to the patient; they can also be used in situa- 
tions, as the throat for instance, where the cups cannot be placed ; and 
as the blood is withdrawn more slowly they are better adapted to 
those cases in which we do not wish to produce the more depressing 
effect of a rapid abstraction of blood. On the other hand, they are 
liable to the objection that the bleeding from them cannot be stopped 
at pleasure so certainly as from the incised wounds of the scarifica- 
tors, and therefore should be as much as possible avoided where we 
apprehend a hemorrhagic condition of the system; for this reason 
cupping is to be preferred in jaundice. They are also apt in some 
persons to excite erysipelas, and therefore inquiry should be made as 
to whether there exists this tendency in the individual ; and their use 
should be scrupulously avoided where there is a possibility of the 
patient receiving the infection of this disease, either from its general 
prevalence at the time, or from the possibility of its being conveyed, 
as in hospitals, by nurses or other attendants. 

Scarification is chiefly employed in superficial inflammation, as of 
the integuments or areolar tissue immediately underneath them, and 
has the advantage of directly unloading the smaller vessels. 

(1.) The effects of general bleeding are commonly stated to be — 
1, a diminution of the force and frequency of the heart's action; 2, a 
derivation of the blood from the inflamed part; 3, a modification of 
the character of the blood itself. 

The blood is the natural stimulus of the heart by which the con- 
traction of its cavities is excited and maintained ; and although the 
heart of some animals will continue to act for a time even after 
removal from the body, yet the effect of loss of blood upon persons 
in health, as well as that of obstruction to the supply of blood to 
the left ventricle in disease, shows that the consequence of a with- 
drawal of this stimulus is a diminution in the force and frequency of 
the heart's action. At the same time it may be observed that this 
depression is not entirely owing to the direct effect of the with- 
drawal of its accustomed stimulus from the heart, but also to the 
rapid removal of the pressure upon the brain and medulla oblongata, 
though the effect of this latter has, as we have already seen in speak- 
ing of syncope, been considerably overestimated. Still it is an 
important fact "that when blood is drawn in the erect posture so 
that the influence of gravitation co-operates with that of the opera- 
tion in weakening the flow of blood to the head, not only are the 



88 TREATMENT OF INFLAMMATION. 

sensations and consciousness of the patient, i. e., the functions of the 
brain and medulla oblongata much sooner affected; but the heart's 
own action is much sooner impaired than when the same quantity is 
taken from a patient lying horizontally, a most remarkable diminu- 
tion of the frequency of the pulsations is thus very frequently 
effected, the pulse falling, for example, from 120 to 60 in a minute, 
at the same time that faintness and transient insensibility are pro- 
duced."* We perceive then that the depressing agency of depletion 
is twofold, — the one more speedy, and at first more powerful, but on 
the other hand more transient, acting through the brain and medulla 
oblongata, and producing an effect like that of sudden concussion or 
shock, — the other more gradual, but more persistent, arising from 
the abstraction of the vital stimulus ; and so distinct are these modes 
of action, that some persons, even when laboring under inflammation 
of an active character, will, if bled in a full stream, and in an erect 
position, become faint before blood has been drawn in sufficient 
quantity to produce permanent effect upon the disease; although if 
it be drawn slowly, and when the patient is in a recumbent position, 
the desired impression may be produced before faintness comes on. 
This effect of blood-letting upon the nervous system must act also 
upon one of the requisites of a healthy condition in the inflamed 
part, viz., the due supply of nervous influence, and consequently 
materially affect the character of the inflammatory lymph, and its 
subsequent progress towards organization or degeneration. 

(2.) It is not, however, solely by diminishing the injecting force of 
the heart that bleeding acts in relieving the distension and congestion 
of the vessels of the inflamed part; it does so in some degree by 
diminishing the entire mass of blood in the system, but still more by 
what appears to be a withdrawal of the blood from the part affected, 
to that whence the blood is drawn; this effect is termed derivation, 
and the precise mode in which it is brought about requires further 
investigation. Whether, as some have imagined, it is the mere 
result of the contractility of the vessel causing a flow to any part 
where an opening is made ; or whether, as Haller, with perhaps more 
reason, considered, it cannot be explained upon merely mechanical 
principles, certain it is that this derivation may be seen to take place 
in the smaller vessels when one of them is punctured under the 
microscope ; and according to Haller the movement often occurs to 
such an extent as actually to invert the natural course of the circu- 
lation. Such being the case, it is to be expected that general blood- 
letting must exert a similar influence upon the blood stagnating in 
inflamed parts ; and that some such result is produced independently 
of the diminution of the force of the heart's action, is shown by the 
fact of blood-letting having the effect of reducing inflammatory 
action in certain cases where the pulse is very small, as in inflamma- 
tion situated about the stomach; and where also the pulse, after the 
bleeding, becomes fuller or stronger than before. 

It may hence be inferred that topical bleeding would be the most 

* Alison's "Outlines of Pathology and Practice," p. 217. 



EFFECTS OF BLEEDING. 89 

effectual for the purpose of derivation, and such is actually found to 
be the case in practice ; and indeed it is when the force of the heart's 
action has been reduced by general bleeding, or has subsided under 
the use of other remedies, or from the disease assuming a less acute 
form, that we find topical bleeding of such marked efficacy in 
relieving the local congestion. At the same time general bleeding 
is not without its derivative effect, as seen in the instance of abdomi- 
nal inflammation already alluded to; and topical bleeding in some 
forms exerts a considerable influence upon the action of the heart 
and large vessels; as when blood is taken freely by a dexterous 
cupper, and also when leeches are applied to young children, in 
whom they may be regarded as equivalent to general bleeding; so 
that the primary object of general bleeding for inflammation is to 
reduce the action of the heart, although at the same time it exerts a 
considerable derivative influence ; whilst, on the other hand, although 
we use topical bleeding, as cupping or leeches, chiefly with a view to 
its derivative agency in relieving the gorged vessels of the inflamed 
part, we must not forget that it exerts some influence on the action 
of the heart. 

There is another circumstance which is also important in practice, 
tending to show that the derivative action of local bleeding is not to 
be explained upon merely mechanical principles, namely, that it is 
useful when applied to the surface of the body, near an inflamed 
internal organ, (as to the surface of the chest corresponding to an 
inflamed portion of the lung,) although there be no continuity of 
vessels between the surface from which the blood is drawn, and the 
inflamed part. 

(3.) There is again another result of blood-letting in inflammation, 
the nature and extent of which require further elucidation still more 
than the former, and that is the alteration produced in the condition 
of the blood itself. We have already seen that the leading charac- 
teristic of inflamed blood is an increase in the quantity of fibrine 
and colorless corpuscles, as well as an increase in the fibrillating or 
contractile force of the former. Now that these conditions proper to 
inflamed blood are reduced by bleeding, we have reason to believe, 
from the effect of two or three bleedings upon the thickness, and 
firmness, of the buffy coat. Whether the cause of this be the abstrac- 
tion of a portion of the fibrine, or whether it consist in diminution 
of its vital contractility, or whether it be brought about through the 
influence of the nerves, we are perhaps at present hardly in a condi- 
tion to determine, though it is very difficult to discard the latter. 

Another important effect of blood-letting, especially if repeated, is 
to diminish the proportion of the red corpuscles, though it must be 
remembered that the decrease in the quantity of this element of the 
blood does not diminish the tendency to inflammation in the system, 
and consequently this consideration weighs rather against the two 
active use of depletion, than in favour of its repeated performance. 

Upon the whole it appears that the diminution of the force and 
frequency of the heart's action, and of the increased arterial current, 
— the restraining the afflux of blood to the injured part, and also the 



90 TREATMENT OF INFLAMMATION. 

correcting that altered condition of the blood (which, though it may 
be the consequence rather than the cause of the inflammation, is no 
doubt effectual in keeping it up), are the immediate results which 
we may hope to obtain by blood-letting ; yet it does not follow that 
we in this way necessarily cut short the inflammation, or that 
the remedy has been without good effect even if the disease has 
extended, or inflammatory effusions have taken place after its use, 
since it is very possible that the intensity of the inflammation may 
have been restrained, and the character of the effusion modified so 
as to favour its absorption; the effect of the bleeding under such 
circumstances being that, in the words of Dr. Alison, " it disposes to 
a favourable termination." Neither, on the other hand, is it by any 
means certain that when a partial subsidence of the inflammation has 
taken place after blood-letting, and the inflammation has afterwards 
extended, or inflammatory effusions of an unfavourable character 
have afterwards taken place, that the use of the remedy has been 
without any ill effect, since it may have modified the character of 
the effusion beyond the point which favours its absorption, and con- 
sequently have promoted its degeneration and disintegration; the 
effect of the bleeding under such circumstances will have been to 
dispose to an unfavourable termination. 

Having now passed in review the different methods of abstracting 
blood, we are better prepared to consider the conditions under 
which it ought or ought not to be performed in the treatment of 
inflammations. That bleeding, when applied at the right time and 
under fitting circumstances, has the power of subduing inflammations, 
equalling or even surpassing that of any other remedy, is a truth to be 
equalled in importance only by another, viz., that when ill-timed as 
regards the period of the inflammation, or performed in defiance of 
contrary indications arising from the character of the inflammation 
or the condition of the patient, blood-letting is as injurious as regards 
the progress of the former, as it is dangerous to the life of the latter. 

The fundamental principles which are to guide us in the use or 
avoidance of bleeding are few and simple, and may be readily inferred 
from what has been stated of the nature of inflammation, and the 
effect of the remedy; that on the one hand it is capable of cutting 
short the inflammation, disposing to a favorable termination, or so 
modifying the character of the inflammatory effusion as to favor its 
absorption ; on the other, it may dangerously or even fatally depress 
the powers of the patient, or so modify the character of the effusion 
as to promote its degeneration and decay, and consequently render 
it incapable of being either organized or absorbed. 

It is not indeed possible here, to give special rules for the applica- 
tion of these principles, these must be reserved till we come to speak 
of special inflammations; but experience has furnished us with 
certain general indications, which must on all occasions be borne in 
mind. 

First of all we must look to the external conditions affecting the 
patient: thus, in some situations bleeding is generally better borne 
than in others — in the country, for instance, than in large towns; 



INDICATIONS FOR BLEEDING. 91 

and by those living on dry soils and elevated situations, than by 
those in low or marshy districts. Again, the condition of the atmos- 
phere at certain times, or, what was called by Sydenham, the epidemic 
temperament, has a considerable influence in this respect; e. g., 
during the prevalence of several epidemics, bleeding is very ill 
borne, not only by those in whom inflammation may have super- 
vened when suffering under that epidemic; but also by others in 
whom it would appear to have arisen independently of it. 

Old persons and young children, generally, do not bear loss of 
blood well, though in both, especially the former, it is sometimes 
unavoidable. Women, again, are less tolerant of bleeding than men ; 
persons of large bulky frames, than rather more spare but muscular 
subjects. Those who have lived poorly, that is to say, without a 
sufficiency of animal food; those who have been addicted to intem- 
perance, or exhausted by long-continued previous disease, are espe- 
cially susceptible of the depressing effects of the loss of blood ; and 
it may be added, that those who live, as it is termed, generously, are 
less tolerant either of disease or blood-letting, than those who are 
abstemious of the use of alcoholic liquors. When, again, inflamma- 
tion supervenes upon fever, especially of a typhoid character, there 
is not the same power to bear loss of blood, as in the same inflamma- 
tion occurring under different circumstances. 

The state of the pulse, again, affords valuable indications as to the 
tolerance of blood-letting. It will be the greatest when there is a 
frequent and strong contraction of the ventricles, united to a forcible 
contraction of the artery, which is the condition produced by active 
inflammation in a sound constitution ; and which, as we have already 
explained, manifests itself by a frequent, hardly- compressible, and 
moderately full pulse, which is also rather sharper than in health, 
owing to the ventricular contractions taking place somewhat more 
suddenly. When bleeding is performed under these circumstances, 
it will commonly be found that the pulse becomes less frequent, 
smaller, and softer; there are, however, cases of inflammation in 
which blood-letting may be of great service, but in which some of 
the above conditions may be wanting, the reasons of which excep- 
tions from the general rule are, however, included in the principles 
just laid down : thus, when the inflammation is situated in the abdo- 
men, if it be near the stomach or duodenum, the pulse is not uncom- 
monly very small, though sharp; the depressing effect upon the 
heart through the great plexus of nerves more than counterbalancing 
the exciting influence of the inflammation; and from an analogous 
cause, viz., the depressing effect upon the nervous centre, we often 
have, in inflammation within the cranium, a sIoav but hard pulse, 
and sometimes an intermitting one. There are again apparent 
exceptions of an opposite character, as, for instance, when one or 
more of those conditions of the pulse are present, which indicate a 
state of the system in which bleeding would be of service, but in 
which such a state does not really exist; thus Ave may meet witli an 
apparently hard pulse in old persons, or those who have lived inrem- 
p^rately, or have followed very laborious occupations; bin here the 



92 TREATMENT OF INFLAMMATION. 

hardness is not in the pulse, but rather in the artery itself, the pulse 
being often abolished by very moderate pressure, the artery remain- 
ing like a cord under the finger. 

The other condition to which we have alluded, viz., the burly 
coat of the blood, is one which presents many exceptions, or seeming 
exceptions, though it is probable these will disappear, as the subject 
is more thoroughly investigated. We have already seen that inflam- 
mation is not the only cause of the burly coat, but that it depends 
partly upon the proportion of fibrine to red corpuscles ; partly upon 
the rapidity with which the latter subside, proportionably to that 
with which the coagulation of the former takes place ; and partly 
upon the presence and proportion of colourless corpuscles. 

Now in inflammation we have observed the coincidence of several 
of these conditions, viz., the large proportion of fibrine, the rapid 
subsidence of corpuscles, owing in a great measure to their aggrega- 
tion in rouleaus, the increased contractilitv of fibrine, and the abund- 
ance of colourless corpuscles ; hence the buffing and cupping of the 
blood, which, in the early stages of inflammation, constitute an indica- 
tion for bleeding. It must, however, be remembered that as the 
change in the blood is, in primary inflammations, probably produced 
by passing through the vessels of the inflamed part, there will ge- 
nerally some time elapse after the commencement of the inflammation, 
especially if it be not of great extent, before there can be produced 
in the blood that change in virtue of which the clot becomes buffed 
and cupped, and consequently the absence of the buffy coat at the 
commencement of an inflammation, and when we have good evidence 
from other sources of its existence, is not to be regarded as a suf- 
ficient proof that the bleeding will not prove beneficial. For the 
same reason we can understand that as long as the inflammatory 
action continues, this altered condition of the blood must be kept 
up, even after the period at which blood-letting is beneficial, as after 
ulceration and suppuration have commenced, so that whilst in the 
former case we are not to regard the absence of the buffy coat as a 
proof of the impropriety of bleeding, we must not, in the latter, 
receive its presence as an evidence of its fitness. Again, there is in 
anaemia a large quantity of fibrine proportionately to the red cor- 
puscles, and therefore one of the conditions favouring the formation 
of the buffy coat, which is accordingly found to occur without the 
presence of inflammation, or any other condition indicating the use 
of the lancet. Not, however, that we are to infer from this, that 
because there exists an anaemic condition, there can therefore be no 
inflammation, for the subjects of anaemia are as prone to inflammation 
as others, or even more so, but we must look for the proofs of its 
existence elsewhere than in the buffy coat. 

The danger of death occuring directlv from the loss of blood, need 
hardly be considered, when the operation is performed by, or under 
the direction of, a duly-qualified practitioner (and by none other 
should it ever be allowed to be undertaken), since there are always 
the premonitory signs of paleness, collapse, cold sweat, failing pulse, 
&c. ; but in estimating the direct ill effects of excessive depletion, we 



INDICATIONS FOR BLEEDING. 93 

must not forget, that after a considerable loss of blood, there com- 
monly ensues a reaction, accompanied by a fulness and sharpness of 
the pulse, and an apparently febrile heat of skin, with a giddiness 
and tinnitus aurium, which may be mistaken by the unwary for a 
return of the inflammatory action, and be supposed to indicate a 
repetition of the bleeding, which if not directly dangerous to the 
patient, would have an injurious effect upon the progress of the 
disease. This state of vascular excitement is, however, tolerably 
well known, and easily recognised, the pulse, which is frequent, full, 
and sometimes even sharp (having what is familiarly known as the 
haemorrhagic jerk), differs from the true inflammatory pulse in which 
bleeding is indicated, in its want of hardness, for it is readily com- 
pressed; the heat of the skin too is never persistent, disappearing 
when the clothes are removed from the part : there is pallor of the 
lips; and the giddiness, and tinnitus aurium are increased by the 
erect, and relieved by the recumbent posture. This state of things 
may indeed co-exist with the persistence of inflammation, but never- 
theless it is a condition, or stage of inflammation, in which blood- 
letting is no longer beneficial. 

The dread of subsequent and permanent injury to the constitution 
by bleeding, is, by some, regarded as chimerical ; yet although the 
apprehension of immediately setting up dropsy may be discarded as 
visionary, there are, neverthless, good grounds for believing that 
when bleeding has been carried so far as materially to diminish the 
proportions of fibrine and red corpuscles, which is among the known 
effects of repeated loss of blood, this deficiency is often very slowly 
repaired, and that, as long as it exists, there will (besides the ill 
effects upon the present inflammation) be a tendency in any future 
inflammation to assume an aplastic or cacoplastic character; and 
further, that this poor condition of the blood has in several instances 
given rise first to functional and afterwards to organic disease of 
the heart, of which dropsy has been one of the least serious con- 
sequences. 

In speaking of blood-letting as a means of procuring resolution of 
the inflammation, we may be supposed to assume that it is applied 
in the early stage of the disease, and before any, or at all events 
extensive, effusion has taken place, and it is to this period that it is 
specially applicable ; but it may not be out of place here to observe, 
that when plastic effusion has taken place, it is to be used with 
caution, since there is great danger of causing the effused lymph to 
break down into suppuration (together with the parts into which it 
has been effused), by diminishing the vital power. It is true, indeed, 
that we commonly have different parts of an organ in different stages 
of inflammation at the same time; so that it is difficult, or rather 
impossible, to lay down any precise rule as to the period at which 
blood-letting ceases to be useful, and, consequently, we must look to 
the constitutional symptoms to guide us. Thus, when there is a 
diminution in the intensity of the febrile symptoms without any in 
the local ones, we may fairly infer that the structural change which 
had been produced by the inflammation is more a matter for con- 



94 TREATMENT OF INFLAMMATION. 

sideration than the inflammation itself; and the recovery from such 
change being a slow process, and one which anything tending to 
depress the vital powers would convert into a destructive one, mea- 
sures having such a tendency, and more especially bleeding, must 
be useless. But if, further than this — there is a change in the cha- 
racter of the febrile symptoms, the heat of the skin becoming less, or 
alternating with chills or perspirations, the pulse more compressible, 
though quicker and more irritable, and the tongue redder, the local 
symptoms either not subsiding or increasing, we have reason to ap- 
prehend not only that the time for blood-letting has passed, but that 
the part which has been inflamed, or, at least, a portion of it, is 
already undergoing a process of disorganisation, or, if a membranous 
surface, that its increased secretion is becoming puriform. 

The kind of inflammation is also important in reference to the 
expediency of bleeding. In scrofulous or aplastic inflammation, not 
only is there greater risk of increasing the disorganisation by reduc- 
ing the vital power; but it is also found, as a mattsr of experience, 
that such inflammations, even at their outset, are little, if at all, con- 
trolled by bleeding, and as the tendency to scrofulous disease is 
increased by debilitating causes and great evacuations, we incur the 
risk of aggravating the primary and constitutional mischief. In 
rheumatic inflammation again, under favourable circumstances, there 
is much benefit from a full bleeding at the very commencement, and 
this benefit is the greater the greater the similarity to ordinary in- 
flammation, and that, too, when there is metastasis of the rheumatic 
inflammation to internal parts, as the pericardium or pleura; and, 
perhaps, in cases such as we have just mentioned, the proneness to 
metastasis is diminished by it ; but where the rheumatic inflammation 
of the extremities has existed for many days, or is of a less active 
character, there is good reason to think that that proneness is in- 
creased, if under the influence of the depletion, the former recedes 
suddenly from the extremities. In gout the use of the lancet is, as a 
general rule, dangerous, as it is still more apt than in the former 
case, to give rise to retrocession of the inflammation, followed by a 
gouty affection of an inflammatory or neuralgic character, of some 
vital organ. 

In specific inflammations of the skin, as erysipelas or small-pox, 
bleeding is to be avoided : and, in all such cases, we have a complica- 
tion with a more dangerous disease, namely, fever ; so that whether 
the inflammation belong, as it were, to the disease, and be essentially 
characteristic of it, or whether it occur only as an accident, the system 
is under the influence of a depressing cause, and the blood in a con- 
dition the most opposite to that which is favourable to its abstraction; 
and it must be further borne in mind, that the agency of this specific 
cause or poison is commonly a more dangerous thing than the in- 
flammation itself, and that there will generally be greater danger of 
reducing the vital power by depletion than of allowing the inflam- 
mation to remain uncontrolled by it; though it is by no means 
generally true that inflammations of this character are subdued by 
bleeding. There are, no doubt, occasional exceptions occuring, per- 



INDICATIONS FOR BLEEDING. 95 

haps less rarely in a rural than a town population, in which the 
depression of the powers of life is the less, and the intensity of the 
inflammation the greater danger, and where it will be the safe course 
to check the latter by early and decisive antiphlogistic measures. 
In estimating the relative amount of these dangers there is of course 
occasion for the exercise of sound discretion ; the greater or less 
tendency to depression in the fever on the one hand, and the cha- 
racter and intensity of the inflammation on the other, requiring to be 
carefully weighed, as well as the nature of the prevailing epidemic, 
and the ordinary considerations of the period of the disease, and the 
age, constitution, habits, &c, of the patient. 

As regards the complication of chronic or non-febrile disease with 
inflammation; when a patient becomes affected with inflammation 
who has been previously the subject of any chronic disease, the effect 
which that disease has already produced upon the constitution will 
be the best and safest guide to direct us in determining the probable 
tolerance of blood-letting, and its probable effect upon it ; at the same 
time, we ought always to be inclined to caution under such circum- 
stances, since the general effect of these diseases is not only to impair 
the nervous power, but often to diminish the solid contents of the 
blood, — e. g.j in cases where there has been any long-continued dis- 
charge connected with the disease, or, where there has been structural 
change, especially in the viscera of the chest or abdomen, by which 
the due elaboration or depuration of the blood is impeded, there is a 
deficiency in the more highly -vitalized ingredients of the blood, the 
fibrine and red corpuscles, upon the abundance of which the toler- 
ance of blood-letting greatly depends. As instances of the above, 
we need merely notice — inflammations occurring in females who have 
suffered from protracted leucorrhcea, — inflammations of the lungs, or 
bronchi in the subjects of old emphysema, — inflammation within the 
abdomen supervening upon the structural change in the liver, and 
— inflammation of serous membranes arising in the subjects of dis- 
ease of the kidneys. Now although none of these complications 
necessarily preclude the use of blood-letting, either general or local, 
yet there is present a cause which depresses the vital powers, and 
often interferes with sanguification, and therefore must retard the 
recovery of the strength after any large evacuation, and moreover 
favour the destructive tendency of the inflammation, where any such 
exists, and which the bleeding would still further accelerate. 

Next to blood-letting as an evacuant in inflammation, is the use of 
purgatives; these, when so used as to affect the surface of the mucous 
membrane of the small and large intestines, have the double effect of 
removing foecal matter, which being lodged there, proves an addi- 
tional source of irritation, and interferes with the action of other 
internal remedies, and — by carrying off serum from the surface of 
this membrane they aid the action of blood-letting, or may even 
prove an efficient substitute for it, where there is reason to apprehend 
that there may not be a sufficient tolerance of it ; and they may be 
so exhibited when there is no ground for dreading inflammation of 
the membrane, though, if pushed too far, they may excite it, or pro- 



96 TREATMENT OF INFLAMMATION. 

duce a depression as great as that which ensues from the abstraction 
of blood. Their best effect is therefore obtained from a few active 
doses at the beginning of an inflammation, so combined as both to 
excite the peristaltic action t of the whole tube, and increase the secre- 
tion from the intestinal membrane. The best fitted for this purpose 
is the combination of jalap and calomel, senna with sulphate of mag- 
nesia, or senna with manna and nitrate of potass, to which last a 
small quantity of tartar emetic may often be added with advantage ; 
the union of several of these will be found most effectual : e. g.. a 
moderate dose of jalap and calomel may be given at once, and a 
draught of salts and senna after a few hours.* 

We have alluded to irritation existing in the gastro-intestinal 
membrane as an objection to the use of purgatives ; but it should be 
borne in mind that there is the greatest caution requisite in their 
exhibition in inflammation of the peritoneal coat of the intestines, 
since the rest of the part inflamed is a most important element in the 
rational treatment of such disease. 

Next in order to purgatives, as evacuants in the treatment of in- 
flammation, are emetics ; these in the first instance effect, as regards 
the stomach, the same object as purgatives, as regards the intestines; 
they remove matter, which being lodged there, would increase the 
irritation, and moreover interfere with the action of other remedies ; 
but, beyond this, several emetics, as antimony, ipecacuanha, and 
colchicum, produce a depression which is often very efficacious in 
the commencement of an inflammation. This may be well illus- 
trated by the effect of a full dose of tartar emetic, or of that drug 
combined with ipecacuanha, in arresting the progress of the inflam- 
mation of the tonsils, termed cynanche. There is, it is believed, 
some danger to be apprehended, in certain instances, from the possi- 
bility of an injurious determination of blood being excited by the 
act of vomiting. The danger from this cause in inflammatory affec- 
tions in the cranium has probably been exaggerated; but, on the 
other hand, when we suspect a tendency to venous congestion, it 
certainly ought not to be disregarded. The same caution is likewise 
applicable to venous congestion within the chest, especially when 
arising from organic disease of the heart. 

Although the use of diuretics has been regarded by many as 
nearly confined to the attainment of one object, namely, the conse- 
quent increase of absorption for the removal of dropsical effusion, 
they may, nevertheless, be employed as important adjuncts to other 

* (1.) R Pulv. jalapse, gr. xv. 
Hydr. chlorid. gr. iij. 
Misce. ft. pulv. ; for a dose. 

(2.) R Magnes. sulphat. g iij. 

Tinct. sennse, g j. 

Vin antim. pot. tart. gtt. xv. 

Infus. sennse, g x. 

Aq. carui. ^ ss. 
Misce. ft. haust ; to be taken four hours after the first. 



DIURETICS. 97 

remedies, in reducing inflammatory action. In order to make this 
apparent, we should call to mind that not only do the kidneys, as 
has been already explained, remove from the blood its redundant 
water, and with it, in solution, all excess in the salts of the blood, and 
such soluble matters as have been absorbed from the alimentary 
canal but have undergone no change in the extreme circulation; 
but they also eliminate highly nitrogenized substances, e. g., urea, 
urates, &c, the products either of the metamorphosis of tissues, or of 
" imperfectly assimilated food;" so that not only may free diuresis, 
where it can be procured, diminish effusion arising as well from 
inflammation as from other causes, but also promote the removal 
from the blood of matter which, if retained, will, by furnishing an 
additional source of irritation, tend to keep up or even to aggravate 
any existing inflammation. There is, however, reason to believe 
that some diuretic substances can effect even more than this: thus 
water, which is, perhaps, the simplest of all diuretics, accelerates the 
removal of all the above-named impurities from the blood, by fur- 
nishing an abundance of the solvent, if it does no more. The action 
of water may often, where the kidneys are healthy, be promoted by 
what may be termed the direct or stimulating diuretics, the agency 
of which depends upon their stimulating the kidneys, probably by 
being carried to them after having been taken up into the circula- 
tion, but which have no chemical agency on organic matter; of this 
class are the vegetable diuretics, squill, broom, juniper, guiacum, 
digitalis, &o. These substances are very useful in exciting the action 
of the kidneys, increasing the flow of urine, though sometimes (and 
this is more especially the case when there is inflammatory excite- 
ment in the system) they fail in producing the result for which they 
were administered, owing to their over-stimulating the secreting 
organ, and by the congestion thus produced impeding its function. 
Nitric ether, and the neutral salts of the alkalies with mineral acids, 
have probably much the same agency, but are less liable to the same 
objections; and there is another class of diuretics which are especially 
applicable in inflammation, "which include the alkalies, their car- 
bonates, and their salts with such acids as in the animal economy are 
capable of being converted into carbonic acid, including the acetates, 
tartrates, citrates of soda and potass."* These remedies, besides 
stimulating the excreting function of the kidneys, and increasing the 
volume of urine voided, actually increase the metamorphosis of 
tissues, and consequently the quantity of the solid contents of the 
urine. 

Now if we add to these facts another equally well known, namely, 
that the alkalies and their carbonates powerfully dissolve albumen, 
and then decompose it into various secondary substances, we can 
perceive at once that this class of diuretics affords a means of reducing 
the quantity of solid contents in the blood, more particularly of 
albumen, which may be turned to account in inflammation in which 

* Vide Lectures on Materia Medica, delivered before the College of Tbysieians in 
1848, by Dr. Golding Bird; published in » Medical Gazette." 



98 TREATMENT OF INFLAMMATION. 

other more depressing evacuants may be deemed inexpedient, or in 
which they have already been carried as far as was consistent with 
prudence. Without, however, pursuing this subject further at 
present, it may be well to remark, that in practice diuretics have 
been found useful adjuncts to other evacuants in the treatment of 
inflammation, and as such have long been used by practical men, 
though the principles upon which their efficacy depended, and the 
rules according to which they should be selected, may not have been 
very clearly apprehended. There is another principle according to 
which diuretics will be found especially serviceable in inflammations 
of the lungs and their appendages, and of the liver, namely, that the 
kidneys are in some measure auxiliaries to those great depurating 
organs, and have a kind of compensatory action to them, so that not 
only may an increase in their action diminish the ill effects which 
would arise in the system generally, from the imperfect depuration 
of the blood through disease of the above-named organs, but also 
diminish the amount of function required to be performed by them, 
and thus favor the condition most essential to the recovery from 
inflammation, namely, rest. 

The next kind of evacuation is diaphoresis, or sweating. The 
effect of diaphoretics in inflammatory complaints is not, as Dr. Alison 
observes, easily referred to any fixed principles; and in those cases 
where a free perspiration is speedily followed or attended by allevia- 
tion of the symptoms of inflammation, we cannot readily determine 
whether the diaphoresis was in any way a cause of the subsidence of 
the inflammation, or only the effect of it, or of some other cause, 
which it shared in common with that subsidence : there may, again, 
be diaphoresis in many inflammations, especially of serous membranes, 
without any alleviation of the symptoms; but there are also other 
inflammations, chiefly those of the mucous membranes, and perhaps 
also some of the secreting organs, as well as rheumatic inflammation, 
in which a free diaphoresis, maintained for several days, is evidently 
beneficial ; so that we must be guided by the nature and seat of the 
disease, in our expectation of relief from sudorific medicines ; but, as 
a general rule, it should be borne in mind that in the active state of 
any inflammation it is inexpedient to make use of diaphoretic 
remedies, the action of which is attended or preceded by any vascular 
excitement — a caution which is particularly applicable to the prema- 
ture and indiscriminate use of the warm bath in the inflammatory 
diseases of children. 

Another class of remedies used for depressing the action of the 
heart and blood-vessels, comprises those medicines which are termed 
sedatives ; of these perhaps the most important is the tartar-emetic, 
or potassio-tartrate of antimony. Whether indeed its depressing 
effect upon the circulation is altogether independent of its nauseating 
.action, may very well be questioned ; but it cannot be denied, on the 
other hand, that the former is often very considerable when the latter 
is very slight, and may frequently be continued long after it has 



SEDATIVES. 99 

ceased. The use of the tartar emetic for this purpose was first practised 
many years ago in this country, but was carried to a much greater 
extent by Easori, an Italian physician, who prescribed as much as 
from 10 to 120 grains in the course of the twenty -four hours. In 
this country, however, it is seldom found that much more than from 
half a grain to a grain can be given at a dose, without exciting some 
degree of nausea, and it has not generally been deemed expedient to 
push it much further; but even thus used it produces, in addition to 
the nausea, a diminution in the action of the heart and arteries, sink- 
ing of the pulse, paleness, softness and moisture of the skin, and often 
a great relief to the symptoms ; and is, therefore, a powerful adjunct 
to other measures in many inflammatory diseases. It is found to be 
specially beneficial in inflammation of the mucous membrane of the 
lungs and air-passages; also of the kidneys, when its use is not con- 
tra-indicated by sickness ; and in the commencement of inflammation 
within the cranium, particularly in those cases where there is high 
delirium without sickness. It is, of course, not eligible in inflamma- 
tory affections of the alimentary canal, but is sometimes very useful 
in those of the bladder and urinary passages. 

There is some difference in the explanation given by authors as to 
the manner in which antimony exerts its influence on inflammations. 
Dr. C. I. B. Williams supposes it to act by reducing the tonicity of 
the arteries, though this can hardly be its sole effect ; since the pulse, 
under its influence, becomes smaller as well as softer, which would 
not be the case if the contractility of the arteries were diminished 
whilst the force of the heart's action remained the same. Laennec, 
who was one of the first to advocate its use in very large doses, at 
one time supposed that it acted as a revulsive or counter-irritant 
upon the mucous membrane of the stomach ; an opinion, however, 
which he subsequently abandoned, and which, if true, must be 
received as an argument against its use, rather than in favor of it. 
Judging from its effects, we should be led to the opinion that it acts 
as a sedative to the whole vascular system, reducing the injecting 
force of the heart, and, consequently, the fulness and volume of the 
pulse — diminishing the contractile force of the arteries, and, as a 
consequence, the hardness of the pulse. The result of these two 
modes of action must be to reduce the force by which the blood is 
driven into the distended capillaries, and enable them to clear them- 
selves by their own contractility. So far, the action of antimony 
upon the heart and arteries does not differ materially from that of 
the abstraction of blood, and the immediate consequences are nearly 
the same, since it sometimes produces a great depression of the 
heart's action, which, when it does occur, is more to be dreaded than 
the syncope from bleeding, as it is the result of the saturation of the 
system by a poison. On the other hand, we can, by carefully-regulated 
doses of antimony, maintain a sedative influence upon the heart for 
a much longer time than it would be safe, or even possible to do by 
repeated abstraction of blood. So that, while antimony in the 
so-called "heroic" dose is, to say the least, a substitute lor blood- 
letting, more dangerous than blood-letting itself, it may often, in mode- 






100 TBEATMENT OF INFLAMMATION. 

rate doses, be used with, great advantage where the loss of blood would 

I CO 

be ill borne ; and used in the same manner after the abstraction of 
blood, it is a very serviceable agent for maintaining the effect produced, 
and thus obviating the necessity for the repetition of the bleeding. 

Digitalis is another powerful means of depressing the heart's 
action, and may therefore afford some assistance in the treatment of 
inflammation; it should, however, be used only as an adjuvant, and 
when there is an unusual quickness of the pulse, more particularly 
in pulmonic inflammations. The great objection to its use is that its 
effects upon the circulation consist almost entirely in its depressing 
the action of the heart; and this has been known to take place so 
suddenly as to produce instant death from syncope, for it should be 
remembered that, being a cumulative poison, it may sometimes be 
taken in moderate doses for a considerable time with apparent impu- 
nity, though at last it acts as if the whole had been retained in the 
system, and was taking effect in one overwhelming dose. 

Colchicum is another sedative to the vascular system, the action 
of which appears to be, in the main, similar to that of digitalis: 
though it is believed, and not without reason, to have moreover a 
specific effect upon gouty and rheumatic inflammations, but it is 
liable to the same objections as digitalis in the treatment of common 
inflammations, against which we possess other and safer remedies. 

Amongst the agents acting as sedatives to the vascular system 
when the inflammation is near the surface of the body, is cold. This 
remedy, according to Dr. Alison, causes constriction in the dilating 
vessels, and prevents those congestions and stagnations of blood 
which seem to be essential to the inflammatory process. In order, 
however, to be effectual, it must be applied continuously, and for 
some hours together, otherwise its use will be followed by a reaction 
of the circulation of the part, and a return of the inflammation with 
increased intensity. TV~ken the inflammation is severe and extensive, 
it is difficult to do this without risk of the injurious effects of cold 
upon the system : and where it is of a character liable to metastasis, 
this remedy cannot be applied without great danger. There is one 
class of internal inflammations in which it has been esteemed as 
peculiarly beneficial, viz., those situated within the cranium. 

It has already been stated that, associated with inflammation, and 
probably as a part of the inflammatory process, is great nervous 
excitement or irritability. This is little if at all subdued, and in 
some subjects even increased, by bleeding; or, if diminished for a 
time, it is apt speedily to reappear and aggravate the disease. For 
counteracting this irritation, opium is especially serviceable, and. is, 
therefore, applicable to those cases in which the inflammation is 
attended with much pain, and where the nervous irritability, together 
with an apparent feebleness of the circulation, or poorness of the 
blood itself, seem to contra-indicate further depressing measures. In 
the commencement of inflammation it is rarely used as the principal 
remedy; but combined with calomel and antimony it constitutes one 
upon which the greatest reliance is placed in this country. It is, 
however, but rarely admissible in inflammations within the cranium, 



MERCURY. 101 

and also in thoracic inflammations there are special cautions to be 
observed in its exhibition. 

The various other nervine sedatives, conium, hyoscyamus, &c, 
hardly require a special notice in reference to the treatment of 
inflammation; they are indeed often valuable auxiliaries, but are 
employed chiefly to allay the irritation, so as to give time and oppor- 
tunity for the action of other remedies. 

One other medicine remains to be considered, the value of which 
in the treatment of inflammation, though apparently overlooked by 
most continental physicians, is highly and deservedly appreciated by 
British practitioners, and that medicine is mercury. It is not indeed 
to be denied that its usefulness, like that of all other medicines, has 
been at times greatly exaggerated, or that it has sometimes been 
indiscriminately applied, so that, that misapplication has been 
followed by the most disastrous consequences; still, when proper 
regard is paid to the character and period of the inflammation as 
well as to the state of the system generally, it will be found one of 
the most efficient remedies if not the most. 

As regards the action of mercury and the best forms of its adminis- 
tration, it is sufficient for our present purpose to state that mercurial 
preparations have the effect, especially when administered in repeated 
doses, of increasing the secretion from the salivary glands, the liver, 
the mucous membrane of the intestines, and probably from the pan- 
creas and kidneys also, and in so doing, it causes an increased flow 
of blood to those organs, and hence it has been proposed to explain 
its action, in the earlier stages of inflammation, upon the principle of 
derivation, though it is more probable that at this period it is chiefly 
serviceable as an evacuant. 

It is, however, when given in repeated doses, and when the inflam- 
matory effusions are taking place, that it exerts its greatest influence, 
either for good or for evil, upon the progress of the disease ; for the 
effect of mercury is an inflammation of a particular or specific kind, 
the gums becoming swollen, or, as it is termed, spongy, under its in- 
fluence, and after a time, ulcerated. This inflammation is in fact of an 
aplastic character, tending to suppuration and ulceration, and conse- 
quently favouring the effusion of corpuscular rather than of fibrinous 
lymph, or when lymph is effused, promoting its degeneration rather 
than its organization. It must be apparent from this, and from what 
has been already said of the subsequent progress of inflammatory 
effusion, that the effect of mercury, carried so far as to produce 
ptyalism, or an approach to it, must be beneficial or the contrary, 
according to the constitution of the patient and the seat and character 
of the inflammation, since it may in some cases bring about that 
amount of degeneration which is most conducive to the reabsorption 
of the effused matter, but in others it may hurry this degeneration to 
an extent rendering the effusion incapable of reabsorption, and there- 
fore fit only to be expelled from the system by suppuration and 
ulceration : and again — as we have seen that the effect of the inflam- 
mation upon the pre-existing tissues is to diminish their vitality, and 
favour those degenerations in them which we have spoken of as liable 



102 TREATMENT OF INFLAMMATION. 

to occur in the new matter ; — it must follow that mercury, by favour- 
ing such changes, may cause the destruction of those tissues into which 
the inflammatory effusion has taken place. 

The action of mercury is not, however, limited to any particular 
tissue, but under its influence, nutrition languishes and absorption 
proceeds more rapidly. It produces, moreover, marked effects upon 
the blood itself, diminishing the quantity of the red corpuscles, and 
probably that of the fibrine also, and it is possibly in this manner 
that it determines the formation of the less highly-vitalized corpus- 
cular lymph in preference to the more highly- vitalized fibrinous 
lymph. It may indeed be objected to this view of the action or 
mercury, that granulations form and ulcers heal under its influence, 
though this objection is rather apparent than real, for such ulcers have 
commonly a hardened base and edges, so that the vessels supplying 
the granulations may have been strangulated by plastic matter, the 
material of such induration. 

It is not, however, as a simple remedy that mercury is most used, 
or is most efficient in the treatment of inflammation. When it is com- 
bined with opium, and, if there be nothing to contraindicate it, with 
antimony, it constitutes a new remedy especially applicable to the treat- 
ment of many forms of inflammation ; for whilst, as we have already 
seen, the mercury exerts a peculiar influence upon the capillaries, and 
probably upon the blood as well, the antimony has a sedative influ- 
ence upon the action of the heart, reducing the force, by which the 
blood is propelled to the part, and the inflammatory action maintained. 
The opium acts not only in preventing the mercury from running off 
by the bowels, but also as a sedative to the nerves. By this combina- 
tion, then, we are furnished with, perhaps, the most efficient of internal 
remedies for the treatment of inflammation of serous and fibrous tis- 
sues, and also of the pyrenchymata of the viscera. The best mode of 
exhibiting it is, having first of all bled the patient to approaching 
syncope, (where the nature of the disease and his general condition 
appear to justify such a measure,) to administer one of the pills in the 
formulae (3) (4),* when the skin is harsh and dry, and the bowels not 
irritable, the draught (5) may be administered in the interval. The 
quantity of the calomel as well as of the opium may, however, be 

* (3) R. Hydrarg. chlorid. gr. ij. 
Opii, gr. ss. 
Antim. pot. tart. gr. J. 
Conserv. ros. q. s. 
Ft. pil. ; to be repeated every 4th or 6th hour. 

(4) JR. Hydr. chlorid. gr. ij. 

Opii, gr. j. 

Antim. pot. tart. gr. |-. 
Conserv. ros. q. s. 
Ft. pil. ; to be repeated every 4th or 6th hour. 

(5) R. Antim. pot. tart. gr. £. 

Liq. ammon. acetat. 3 iii. 
Mist, camph. 5 v. 
Ft. haust. 



MERC IT BY. 103 

varied according to the particular circumstances of every case. It 
will generally be found, after this plan has been continued until the 
gums become slightly affected, that the constitutional symptoms and 
the signs of the local disease begin to subside; sometimes, indeed, 
this will take place without any evidence of the specific action of the 
mercury. 

From what has been already said (p. 52, et seq.,) it must be apparent 
that when we have reason to apprehend that the inflammation is of a 
destructive rather than of a plastic character, the use of mercury, if 
not altogether laid aside, is to be diminished, and its effects upon the 
system, as well as upon the local disease, carefully watched. For the 
same reason we must use it more cautiously when the inflammation 
attacks a tissue in which it is likely to give rise to puriform effusion 
than when it affects those which ordinarily pour forth plastic lymph : 
thus in inflammations of the mucous surfaces it must not be used so 
freely as in those of the serous membranes, of the areolar tissue, or 
of the parenchymatous viscera. There are also certain states of the 
system in which there is a diminished power of throwing out plastic 
lymph, of which a remarkable instance is afforded in the tuberculous 
or scrofulous diathesis. As this want of power often depends, in great 
measure, upon the deficiency in the blood of fibrine and red cor- 
puscles, especially the former, mercury is to be used with the greatest 
caution, since by its tendency to aggravate the constitutional fault it 
favours the unhealthy and destructive action which inflammation in 
such constitutions is pecularly apt to assume. In those also in whom 
there exists the condition of the blood already described under the 
term ansemia, there is an extreme susceptibility of the action of mer- 
cury, whether the ansemia be spontaneous, or whether it be the result 
of loss of blood, of other discharges, or of visceral disease; in such 
subjects not only is there the greatest danger of the inflammation 
assuming a destructive character under the influence of mercury, but 
also its specific effect upon the mouth and gums is apt to take place 
with the greatest violence, leading to excessive salivation, ulceration, 
sloughing, and necrosis of the jaw-bones; but even where there are 
no signs by which we might suspect the intolerance of mercury, we 
sometimes find furious salivation set up by very moderate doses, and 
sometimes when we do suspect this intolerance we are compelled 
to run the risk of its consequences rather than let an inflammation 
proceed uncontrolled which has resisted other means, or in which 
they would be inapplicable. A vast number of remedies have con- 
sequently been suggested for checking salivation ; purging and 
blistering behind the ears are undoubtedly of service for this pur- 
pose, and the various astringent gargles are useful in ordinary cases, 
as those of alum, or what is better, of alum, bark, and myrrh ; (6)* 

* (6) R. Aluminis, 

Tinct. myrrh re, 
Mellis ros. aa 3 j. 

Decoct, cinchoute cordifol. 5 xiv. Misce. 
For a ga* gle. 



104: TREATMENT OF INFLAMMATION. 

the chloride of soda (7)* gargle is also to be recommended when 
there is a very offensive foetor. That of brandy with an equal quan- 
tity of water, recommended by Dr. Watson in his lectures, is perhaps 
the best of all where the flow of saliva is excessive, and the soreness 
of the gums very great. Very destructive sloughing, which some- 
times ensues, will however be often best counteracted by bark and 
wine and the use of some stimulating application, such as the gargle 
of nitric acid. (8)f 

In the latter stages of inflammation, when the time for general 
bleeding — for medicines which exert a sedative influence upon the 
circulation, and commonly, also, for mercury, has passed; though 
often whilst there still remains opportunity for the useful employ- 
ment of local bleeding, there is frequently need for another class of 
remedies, differing in their effects from those which have been men- 
tioned already, or rather opposed to them — viz., stimulants. These 
are in the main chiefly available for the attainment of the fourth 
object proposed in the treatment of inflammation — "Where one of 
the results of inflammation must ensue, the leading that process to a 
favourable termination." — The particular instances in which these 
results occur requiring such support will be specially noticed here- 
after. They may perhaps be generally included in — "those cases in 
which a long process of absorption, ulceration, or granulation has to 
be gone through, and in which a certain strength of habit is neces- 
sary, that these processes may go on favourably."^: 

There are, indeed, other conditions of the system which have been 
already noticed as indicating a tendency to one of the modes of 
fatal termination of inflammation, viz. — by depression of the moving 
powers of the circulation, — in which the cautious but continued use 
of stimulants may be the only means by which the life of the patient 
can be preserved. There are cases again of inflammation of the 
mucous surfaces, or, of a specific character, in which there is an 
asthenic congestion of the minute vessels, where the inflammation 
subsides and the symptoms are relieved by remedies of this class. 

We have hitherto made no special mention of the use of counter- 
irritants in the treatment of inflammation, though they have been 
casually alluded to in speaking of metastasis, and one of the modes 
by which they act was noticed in connexion with bleeding under the 
term derivation. The object, then, of counter-irritation is to imitate 
this metastasis, and make it available for the purpose of cure, by 
transferring to the surface an inflammation which is going on in 
some deep-seated part or internal organ. It must, however, be 

* (7) &. Liq. sodse chlorinat. g vij. 
Aq. distillat. g vij. Misce. 
For a gargle. 

f (8. R. Acid, nitrici. ttl xxiv. 

Aq. distillat. ^ viij. Misce. 
For a gargle. 

J Alison's "Outlines of Pathology and Practice," p. 250. 



TKEATMENT OF INFLAMMATION". 105 

remembered as a most important rule in practice, that this mode of 
relief cannot be attempted in every stage of the inflammation with 
equal chance of success, or safety to the patient. At the very com- 
mencement of an inflammation termed intercurrent, that is to say, 
supervening in the course of another disease, we often obtain a con- 
siderable mitigation of pain, and sometimes check the inflammation 
by the application of some substance capable of quickly exciting one 
which shall be superficial, and likely afterwards to subside speedily 
by spontaneous resolution. Beyond this, however, it is highly inex- 
pedient to employ counter-irritation till a more advanced period — 
until, in fact, the fever has in some measure subsided, and the local 
inflammation is assuming a more chronic character, or is passing into 
a state more nearly approaching passive congestion, or has given 
rise to some of its characteristic exudations ; for if it be employed 
too early, the additional inflammation excited by the counter-irritant 
accelerates the heart's action, and perhaps, too, increases the inflamma- 
tory condition of the blood, and may thereby aggravate the primary 
disease; but if it be done after the skin has become cooler and more 
moist, and the pulse less frequent and softer, it will generally happen 
that a great mitigation of the symptoms ensues, and in many forms 
of inflammatory effusion, as for instance into the pleura, there is no 
more effective measure towards its absorption than the application of 
a blister. In chronic inflammation, on the other hand, counter-irri- 
tation is almost always applicable. 

When we wish to relieve the pain of an inflammation not attended 
with much effusion — when, in fact, the nerves seem principally 
involved — such counter-irritants as produce a considerable effect 
upon the sentient nerves are to be preferred ; e. g., what are commonly 
termed rubefacients: when, again, we wish to restrain or remove 
inflammatory exudation, a counter-irritant causing considerable effu- 
sion under the cuticle is to be preferred, the vesication being after- 
wards healed as speedily as possible, and the vesicatory repeated 
after a short interval in the same or a neighbouring part. When 
again we wish to check suppuration and ulceration of a chronic 
character going on in an internal part, those counter-irritants will be 
best fitted for our purpose which keep up a discharge of puriform 
matter. If there is chronic inflammation, producing the slow effu- 
sion of lymph or serum, or some perversion of nutrition, as in the 
cases of chronic inflammation with thickening of serous or fibrous 
structures, or chronic changes in parenchymatous viscera (e. g., the 
earliest stages of phthisis pulmonalis,) the best mode of counter- 
irritation consists in the repeated or continuous application of sub- 
stances which stimulate the nerves and vessels without producing any 
great vesication. When, indeed, such change is suspected to be 
going on with great activity, counter-irritation of such a nature as to 
produce a considerable puriform discharge is sometimes serviceable, 
as setons and issues ; not so much on account of the discharge itself, as 
the revulsive action of the hyperemia accompanying that discharge. 



106 TYPHOUS, SCROFULOUS, 



VII. 

TYPHOUS, SCROFULOUS, AND TUBERCULOUS 

DEPOSITS. 

Closely connected with the subject of inflammation, and generally 
the result of one of the varieties of that process, are certain morbid 
products which show a very low degree of organization throughout 
their whole progress. These constitute a class of pseudo-plasmata of 
Vb'gel and other authors, which, in their molecular structure, as well 
as in the concomitant local phenomena, are closely allied to ulcera- 
tion. It is characteristic of this class of deposits that they do not 
commonly remain local, but appear simultaneously on several parts 
of the body, owing probably to the same cause which gave rise to 
the first pseudo-plasma becoming repeated in its vicinity or in a dis- 
tant part of the body. It is to this disposition in the morbid action 
to repeat itself, rather than to any essential difficulty in the healing 
of the cavities and ulcers, caused by these depositions, that the 
extensive destruction, which they often produce, is mainly to be 
attributed. 

These deposits are described by Vb'gel under the names of — I. The 
typhous deposit, — II. The scrofulous deposit, — III. Tubercle, a clas- 
sification which is here adopted as most convenient for the purposes 
of practical medicine. 

" The period which elapses between the deposition and the soften- 
ing of these deposits, or epigeneses, is very different in individual 
cases ; it may vary from a few days or weeks to several months. In 
general the softening extends to the enclosed normal tissues, and the 
united product opens for itself a passage and is discharged externally. 
An ulcer is thus formed : this either spreads by the continuance of 
the original process (new deposition with softening) in the surround- 
ing parts until it terminates in death, or the ulcer heals by cicatriza- 
tion, whilst the loss of substance is repaired by permanently-organized 
epigeneses. In other cases the softened mass does not become dis- 
charged, but is gradually resorbed, and the loss of substance is repaired 
by a similar cicatrization to that which occurs in the preceding case. 
Sometimes the reparation is interrupted by the deposition, instead of 
softening, becoming converted into an earthy or cretaceous mass, and 
thus forming a concretion."* 

I. In most cases of that variety of fever to be described hereafter 
either as typhus or typhoid, pathological deposits take place in dif- 
ferent parts of the body, most frequently in the intestinal canal im- 
mediately underneath the mucous membrane, and above all, in Peyer's 
glands near the termination of the ileum, more rarely in the spleen, 
in the lungs, and in the trachea. These formations consist, at the 

* Vogel's Pathological Anatomy, by Day, p. 271. 



AND TUBEECULOUS DEPOSITS. 107 

commencement, of yellowish or whitish masses, of different degrees 
of consistence, deposited amongst the normal tissues, which, together 
with those tissues, undergo the process of softening and ulceration 
above described, and either heal by cicatrization or continue until 
the death of the patient. 

These deposits consist — 1, of an amorphous stroma or floor to the 
ulcer ; 2, of minute moleculer granules, sometimes interspersed with 
fat globules; 3, of imperfect cells or cytoblasts. These three ele- 
ments are present in very uncertain proportions, the granules, however, 
being generally in excess. When softening takes place the amor- 
phous matter disappears, leaving the granules and cells suspended in 
a fluid ; the softening mass frequently containing unsoftened particles 
of considerable size, which become isolated by the disorganization 
of the surrounding parts, and are thus discharged as agglomerate 
masses* 

II. The scrofulous deposits occur in that state of the system com- 
monly known as the scrofulous diathesis, or scrofulosis, and in their 
elementary composition bear an exact resemblance to the preceding ; 
the only difference being their mode of deposition, which takes place 
much more slowly and under a different condition of the system. 
They exhibit, however, great variations in their anatomical structure, 
being sometimes dense and firm, sometimes lardaceous, and sometimes 
soft and friable. Like the typhous matter, they consist of an amor- 
phous stroma, granular matter, and imperfect cells or cytoblasts. 
Softening does not, however, always ensue in scrofulous deposits, 
but, in many, the calcareous deposition becomes predominant, and 
the result is an earthy concretion.f 

III. The most important, however, of this class of deposits is tubercle. 
This word was at one time very indiscriminately applied, but more 
lately it has been endeavoured to restrict it to certain pathological 
exudations, the result of a specific morbid tendency termed tuber- 
culosis ; though perhaps sufficient care has not been taken to establish 
the proposition that tuberculosis is always the cause and not the 
effect of tubercles. 

Tubercles are described by Dr. Carswell as consisting of a pale 
yellow or yellowish-grey, opaque unorganized substance, and there 
is much truth in this description, with the exception of the term 
unorganized. The fact is, that tubercles are unorganiza£/e, that is to 
say, incapable of any higher degree of organization, but they are not 
on that account unorganized 

Tuberculous matter is composed of different elements occuring in 
different proportions, but corresponding essentially with those of the 
typhous or scrofulous matter already described; these are, 1, a trans- 
parent, amorphous, vitreous stroma, occurring in large masses, and 
closely resembling coagulated rlbrine ; 2, minute molecular granules, 
occuring in masses of a brownish colour; some of these appear to be 
modified protein compounds, others consist of fat, and some of cal- 
careous salts; 3, imperfectly-developed cells and cytoblasts, with or 

* Vogel, opus citat. f Ibid. 



108 TUBERCULOUS DEPOSITS. 

without nucleoli ; the degree of organization of the tubercle depend- 
ing upon the prevalence or deficiency of these cell formations.* 

" With respect to the origin of tubercle there can be no doubt 
that its formative substance is secreted from the capillary vessels in 
a fluid form, in the same manner as the typhous matter; and it 
afterwards fills up all the interstices of the tissue in a manner too 
perfect to be accomplished by any substance which was not originally 
fluid. Probably this secretion results from the same causes as that 
of fibrinous dropsy generally, and is preceded by a local hypercemia of 
the participating capillaries?^ 

It has been said that the different elements of tubercle occur in 
very different proportions, and this difference gives rise to what have 
been termed the varieties of tubercle. Thus we have the gray semi- 
transparent tubercles of the size of millet-seeds, with fibres and 
nucleated cells ; and the opaque, crude, or yellow tubercles in which 
we do not find even these traces of definite structure, since the matter 
of which they consist is altogether granular; between these we have 
every possible gradation depending upon the different proportions 
of the cell formations — the fibrinous matter or stroma — and the 
granular matter. It is here, indeed, that the grey tubercle in the 
progress of its development approaches more nearly to the yellow, 
from the increase in the proportion of granular matter ; but there 
can be no doubt also that the granular matter may preponderate 
from the first, since we often meet with the yellow tubercle in ap- 
parently the very earliest stages of development. 

Of the elements of which these tubercles consist, the amorphous 
stroma is always present from the first, as are generally the granules ; 
but the imperfect cells make their appearance later, and appear to be 
the result of an abortive attempt at organization. 

Tubercles rarely remain stationary as to development, though of 
some, consisting of the semi-transparent stroma, the progress is often 
for a long time very slow ; but the ordinary course of these bodies 
is to soften, which is brought about by the softening of the fibrinous 
matter or stroma, by which the cells and granular matter being set 
free, make a sort of emulsion with fluid formed or secreted in the 
distintegration of the fibrine. This process of softening and dis- 
integration is not, however, confined to the tubercular matter, but 
the tissues in which that matter has been deposited, are involved in 
the same disorganization, and break up, more or less rapidly, accord- 
ing to the nature of each ; and the product of their disorganization 
mixing with that of the tubercle, we have a thick apparently puri- 
form matter consisting of an organic debris saturated with serous 
fluid. This mass has generally a tendency to make its way to the 
nearest cutaneous or mucous surface, like the pus of an abscess. In 
some few cases the fluid becomes reabsorbed, leaving some of the 
tubercular matter as a compact mass, in the cavity formed by the 
destruction of the tissues : this matter sometimes undergoes a species 

* Vogel, opus citat. f Ibid. 



DEVELOPMENT AND PROGRESS OF TUBERCLE. 109 

of fatty degeneration, in which case it is probable that it may be re- 
absorbed and the cavity cicatrized. 

In other cases, again, the calcareous matter, which is generally 
present in greater or less proportion in the granules, continues to 
increase, and the other matters being removed by absorption, the 
tubercle becomes converted into a white chalky mass generally sur- 
rounded by a dense cicatrix. 

There may exist every variety in the mode in which tuberculous 
matter is deposited relatively to the surrounding parts. It may be 
deposited in nodules of various sizes, constituting what are com- 
monly termed tubercles, and which, when very minute, yet at the 
same time distinct and visible to the naked eye, are known as miliary 
tubercles. In other cases the tuberculous matter is diffused through 
the tissue of the "whole or greater parts of an organ, constituting 
what is commonly termed tubercular infiltration. It is not, however, 
always easy to draw the line between these forms of tuberculous 
deposit, since they merge into each other by almost insensible differ- 
ences, and frequently we find every gradation co-existing in the same 
organ. It often happens, too, that we find other pathological forma- 
tions, such as pus cells or fibrinous exudations, surrounding the 
tubercles; these are possibly the products of the disorganization of 
the tissue in which the tubercle has been deposited, or the result of 
the irritation excited in that tissue by the tubercle acting much as a 
foreign body. It is remarkable that these formations at the surface 
of the tubercles are not influenced by the nature of the deposit, or, 
in other words, they are not assimilated to it, a circumstance in which 
tubercle differs essentially from the more highly-organized patho- 
logical formations, commonly described under the term malignant, 
and which possess in a high degree this power of assimilation, excit- 
ing the cytoblasts in their immediate neighbourhood to a similar 
development. As the extension of the tuberculous deposit, which 
almost always takes place, depends upon its continual deposition 
(arising from the as yet unexplained cause, the tuberculous diathesis), 
and not upon any controlling influence exercised by the tubercles 
themselves, the cavity produced by the softening of a mass of tuber- 
cles may heal ; and therefore the cure of any of the tuberculous dis- 
eases of different organs, to be hereafter described, is not a pathological 
impossibility, although the arrest of the disease is rare, owing to the 
tendency to this continual deposition. 

Of the real nature of the tuberculous deposit we indeed know 
nothing except by its effects, though "its presence is, in a great 
number of instances, marked by external and unequivocal signs, 
although they appear under two conditions so different that nothing 
but the fact of their frequent association with scrofulous disease 
would lead us to consider them as marks of a similar condition of 
the body. In one we find what may truly be called the sanguineous 
temperament; the fair complexion, light hair and eyelashes, blue 
eyes, slender form, long fingers, and contracted nails, fine, white, and 
regular teeth, or in the male, the ruddy complexion, with the hair 
and whiskers inclining to red, and with this there is associated a 



110 TUBERCULOUS DIATHESIS. 

peculiar liveliness, activity, and susceptibility of mind. In the other 
we have the dark and swarthy complexion, perhaps the opaque white 
skin, with black eyes, long dark eyelashes and dark hair, the thick 
upper lip, and often a more sturdy form, short fingers, and nails 
wide and large, with the slower intellect and less energetic dis- 
position."* 

This diathesis is further characterised by the manifestation in early 
life, often in infancy and childhood, of a tendency to certain diseased 
actions ; thus in such persons we find enlarged glands in the neck or 
groin, chronic inflammation of the mucous membrane, especially of 
the conjunctiva and of the lining of the air-passages; the tendency 
to the formation of small vesicles often about the angles of the mouth 
and behind the ears, constituting the " sore ears" of the nursery ; a 
liability to livid chronic inflammation of slight wounds. The pulse, 
too, in persous of this constitution is commonly frequent, the heart 
irritable, the veins large and often conspicuous through the trans- 
parent skin. Young children, in whom there is a strong scrofulous 
tendency, have frequently a softness of bone, rendering them rickety, 
often rather large heads, of which the fontannelles and sutures are 
slow in closing, tumid abdomens, or narrow chests : they are also very 
excitable, and have frequently a precocity of intellect. 

The most frequent cause of the tuberculous diathethis is a con- 
genital and hereditary predisposition, which predisposition is, of 
course, far greater where the tendency has previously existed in the 
families of both parents, and shows itself in the greatest intensity in 
the offspring of marriage between relations in whose family the taint 
has already existed. There is, however, no doubt that it may be 
favoured and even induced, by circumstances and habits of life which 
tend to diminish the plastic powers by exhausting the nervous energy 
and impoverishing the blood; and even if it be doubted that tuber- 
culous disease can be set up by such conditions in a subject pre- 
viously untainted, there can be no doubt that parents inheriting no 
tuberculous taint may, under such circumstances, induce a state of 
constitution which^ if it do not, in this way, manifest itself in them- 
selves, will most assuredly do so in their offspring. 

Although we are thus unable to determine the essential character 
of the tubercular diathesis, and the causes to which it owes its 
origin in the first instance, we are nevertheless able to state with 
tolerable confidence certain circumstances or conditions which favour 
its development. Of these the chief are, 1, Climate ; 2, Age ; 3, Mode 
of Life; 4, Employment; 5, Diseases. 

(1.) As regards climate, it is certain that tuberculous diseases are, 
upon the whole, more frequent in cold than in warm ones,f though 

* Bright and Addison's Elements of Medicine. 

f [Tuberculous diseases occur as frequently in -warm as in cold climates. They are 
met with less frequently in cold, dry, equable climates, than perhaps in any other. 
In Stockholm, the deaths from tuberculosis of the lungs amount to one-fifteenth of the 
entire mortality, while in London, Paris, and Berlin, they amount to nearly one-fifth. 
In Rome, Naples, Madrid, Lisbon, Marseilles, Malta, the Ionian Isles, and the north of 
Africa, the proportionate mortality is almost as great as in England. In the East Indies 
it has been recently shown by Dr. Wilson, that tubercular disease of the lungs is of 



DEPOSITION OF TUBERCLE. Ill 

we are not to ascribe this solely to the influence of the former 
in inducing the tuberculous diathethis; but, as we shall presently 
see, in part, to its exciting that diathesis into activity in particular 
organs. Indeed, a warm climate appears in many instances to 
encourage a susceptibility to tuberculous disease, since we often see 
persons — young persons more especially — who have been brought 
from a warm to a cold climate, become in consequence the sub- 
jects of tuberculated lungs. On the other hand, the same facts prove 
the greater power of a cold climate in calling this diathesis into 
activity when there exists the slightest liability to it. The combina- 
tion of cold and wet, especially if it be associated with sudden 
changes of temperature, seems beyond all other conditions of cli- 
mate to promote the formation and also the development of this 
diathesis. 

(2.) As regards age, there is, perhaps, no period of life which is 
exempt from the invasions of tuberculous disease; it may attack 
even the fcetus in utero, and instances are not wanting of its occur- 
rence in extreme old age. Childhood, youth, and early manhood 
are, however, most liable to it, so that we find by far the greatest 
number of cases of tuberculous disease occurring between the ages 
of 2 or 3 and 85. 

As regards the remaining circumstances which favour the forma- 
tion of the tuberculous diathesis, we may lay it down that they do 
so in so far as they are opposed to healthy nutrition, and conse- 
quently all circumstances which interfere with the digestion and 
assimilation of the food, and the due elaboration and depuration of 
the blood, must of necessity tend to this result. 

A deficient or innutritious food must obviously have this effect; 
and although a vegetable diet may, under some circumstances, (as in 
a tropical climate, for instance,) be sufficient for health, yet it may be 
stated, as a general rule, that a diet deficient in animal food, especi- 
ally during childhood and youth, is one of the circumstances which 
predispose most strongly to scrofulous disease. Scanty or unequal 
clothing, [in cold and changeable climates,] again, has the effect of 
impeding the uniform and regular distribution of the blood, and con- 
sequently favours local congestions, especially of internal organs, 
which not only accelerate the deposition of tuberculous matter in 
those organs where the diathesis exists, but also (according to the 
rule laid down), by impeding the functions of those organs which 
are for the most part concerned in the elaboration of the blood, must 
aid in inducing the diathesis itself. 

There are, however, other conditions in the mode of life which 
affect the establishment of the tuberculous diathesis even more per- 
haps than diet or clothing, amongst which may be mentioned over- 
fatigue, want of proper exercise, of pure air, and of light. Now these 
are circumstances which it is impossible to estimate separately, since 
they are evils which commonly affect collectively the poor classes in 

very frequent occurrence. On the continent of America, it is almost as great in the 
south as it is in the north ; and in the West Indies it is nearly the same as in the 
northern Atlantic States. — Editor.] 



112 DEPOSITION OF TUBERCLE. 

large towns; certain it is that they seem to have a much greater in- 
fluence even than privation; for among the rural population, where 
the latter cause is in nearly, or even quite, as active operation, the 
mortality is far less than among that of crowded cities, where there 
is in addition the want of pure air, and of free exposure to the solar 
ray; and the increased number of deaths in the latter case occurs 
mostly among children and young persons, and is very greatly owing 
to scrofulous disease. It does not appear, however, that sufficient 
importance has been attributed by authors to the latter cause, namely, 
insolation, in preventing the development of disease. The above 
causes act most powerfully in early life, and their effects may be 
strikingly seen in children bred in the dark, ill-ventilated, and ill- 
drained dwellings of the poor in crowded cities, so much so, that it 
is not too much to affirm, that were they not, as is commonly the 
case, replenished by fresh importations from the country, the inhab- 
itants of such places would, in a few generations, become extinct by 
scrofula. 

The same tendency is increased by the debility following many 
diseases, especially fevers and great evacuations, which may be really 
said to impoverish the blood by diminishing the quantity of red 
globules and flbrine ; and by none is this brought about more readily 
than by venereal excesses and the pernicious habit of masturbation 
in either sex. 

Depressing mental emotions as disappointment and anxiety, favour 
the scrofulous diathesis, whilst, on the other hand, the same tendency 
is counteracted by pleasing emotions, gentle mental excitement, 
regular exercise in pure air, and the habit of regular employment. 

Having now glanced at the circumstances, which induce or favour 
the formation of the scrofulous or tuberculous diathesis, we may 
make a few remarks upon those, which excite it into activity, or, in 
other words, promote the deposition of scrofulous deposits in par- 
ticular organs ; and we may lay it down as a general rule, that where 
the diathesis exists the tuberculous deposits will be most likely to take place 
in any organ, at the time ivhen its vascular and functional activity are 
the greatest; and accordingly we shall find, that when from age, 
climate, or other circumstances, an increased afflux of blood is di- 
rected upon any organ, then, if there exist the previous tendency, 
scrofulous disease will be most apt to develope itself in that organ. 

Thus, in infancy, the size of the head is large in proportion to the 
rest of the body, the abdomen holds a middle place in this respect, 
and the chest is the least developed of the three. As childhood 
advances the trunk increases in a greater ratio than the head, but at 
this period the abdomen is much more developed than the chest, and 
it is not till youth or early manhood that the latter acquires its full 
size in proportion to the rest of the body. In nearly the same order 
do we find that tuberculous disease attacks these different regions. 
It cannot be denied that in infancy and early childhood the brain is 
more frequently the seat of tuberculous disease than at any other 
period of life, whereas in more advanced childhood we find that 
tubercles evince a greater partiality for the abdominal viscera ; but 



TUBERCLE. 113 

it is not till youth, or early manhood that the lungs, which are never- 
theless in the aggregate peculiarly obnoxious to tubercles, acquire 
their full liability to them. On the same principle we find that the 
presence of tuberculous matter is very common in the spleen in 
children, in whom, from their extremely active habits, that organ is 
frequently liable to great sanguineous engorgement. Further, it has 
been observed that tubercles are scarcely ever found in the organs 
of reproduction before the age of puberty, though their occurrence 
after that period (that is, after those organs have attained their 
maximum of vascular and functional activity) is by no means in- 
frequent In the intestinal tube, again, tuberculous disease is a com- 
mon occurrence, and it is worthy of notice, that in the majority of 
cases it is confined to the lower portion of the ileum and the caput 
coecum coli, parts of the canal which appear, from their being most 
frequently the seat of hyperemia and mucous inflammation in the 
course of other diseases, to be peculiarly susceptible of vascular 
excitement. 

The effects of climate, in favouring or counteracting the deposition 
of tubercles in the lungs, will afford another illustration of the same 
law, since it is in colder climates that there is the greatest demand 
for the function of respiration, and consequently the greatest func- 
tional activity and most rapid flow of blood through the lungs ; and 
the increase of such activity, occurring when animals or human 
beings are removed from a warm to a cold climate, might be expected 
to act still more powerfully upon the lungs, which have been less 
developed from a less performance of function ; and this is found to 
be a circumstance peculiarly favourable to the deposition of tubercles 
in these organs. This, however, is a question that will require a 
fuller consideration in connexion with the subject of phthisis. It 
may, however, be well here to cite the words of Dr. Alison, that it is 
a "well-ascertained fact that masons, miners, needle-grinders, and 
other artificers who are in the habit of very frequently inhaling 
irritating particles, are peculiarly liable to scrofulous phthisis." 

From what has been stated it is evident that tubercles may be 
deposited independently of inflammation, and also that inflammation 
may occur in subjects, in whom that deposit already exists — and 
that too around the tubercles, and in their immediate neighbourhood, 
without the effused matter assuming the form of tubercle — whence 
we infer that there is no necessary connexion between inflammation 
and tubercle ; at the same time it is also evident, from the circum- 
stance of the tubercular deposit being generally promoted by an in- 
creased afflux of blood to the part so affected, that inflammation, by 
inducing such an afflux, must have a tendency to excite the formation 
of tubercles. 

It must be apparent from the description already given, that the 
occurrence of inflammation in scrofulous subjects cannot be too cau- 
tiously guarded against, and therefore a most important considera- 
tion in the management of such subjects, is the prophylaxis or 
previous guarding or fortifying the patient against it (from itpo and 
(jnAaffso, I guard or defend): for this purpose two objects are to be 

8 



114 PREVENTIVE TREATMENT. 

kept steadily in view : 1, the obviating the morbidly-defective vitality 
of the blood with deficiency of fibrine, which appears to be one of 
the fundamental conditions of the scrofulous diathesis; and 2, the 
removal of all circumstances which tend to excite inflammation, or 
local congestion. The general principles, upon which the first of 
these objects is to be pursued, will be readily understood from what 
has been said of the circumstances favouring the development of 
those conditions, which constitute the scrofulous diathesis : the par- 
ticular application of these principles will be more appropriately 
considered when treating of special diseases. 

The second of the above objects will be most likely to be attained 
by not only avoiding the ordinary causes of inflammation, but also 
by paying particular attention to those circumstances and conditions 
which have been already pointed out as favouring, at the same time, 
the occurrence of congestion, and the development of tubercle in 
scrofulous subjects, and adopting measures to obviate them. 

When, however, inflammation does occur in such subjects, it must 
be met by early but moderate antiphlogistic treatment, since it is of 
the first importance to prevent it going on to produce any of the in- 
flammatory effusions, which, under such circumstances, are not merely 
apt to assume an unorganisable character, but often tend to prevent 
the nutrition of the surrounding textures. It unfortunately happens, 
nevertheless, that these effusions do most commonly take place, either 
in the form of the cheesy matter already described, the white granular 
albuminous matter, or tubercle : and since the effusion of these mat- 
ters is not controlled by the same constitutional remedies which 
check the effusion, or promote the absorption of inflammatory lymph 
in ordinary inflammation, but is rather aggravated by them, and the 
consequent disorganisation of the surrounding tissues accelerated, 
the same line of treatment cannot be persisted in ; and all measures 
which, by lowering the powers of the patient, and impairing the 
vitality of the blood, may be supposed to favour suppuration or 
ulceration, should be suspended, as soon as there is reason for be- 
lieving that any of the above deposits have taken place; and a 
moderately tonic treatment substituted, the means for reducing in- 
flammation being restricted almost entirely to counter-irritants. 

It is, perhaps, after the more acute inflammatory action has sub- 
sided, and when the above-named deposits are taking place that 
iodine, or rather the iodide of potassium, is peculiarly serviceable: 
its power of preventing the separation of true tubercle is, to say the 
least, very questionable ; but if it do not actually effect the absorp- 
tion of the albuminous deposit, it checks its effusion, probably by its 
influence in improving the condition of the blood. 



CHAR AC TEE OF RHEUMATISM. 115 



VIIL 
KHEUMATIC AND GOUTY INFLAMMATION. 

Under the term rheumatism are included several diseases, which 
vary in every respect, except one, ^hich is their being always painful. 
It is by no means impr-° .ole that these diseases, which have re- 
ceived a common name, are essentially different. To avoid as much 
as possible this confusion, we commence with the unquestionable 
form of the disease, acute rheumatism, rheumatic fever, or, as it is 
sometimes called, rheumatitis. 

Acute rheumatism, then, is a specific inflammation, affecting almost 
exclusively fibrous tissues, though sometimes extending to the sur- 
rounding structures by contiguity. It attacks chiefly the larger 
joints, especially the knees, wrists, shoulders, elbows, and ankles. 
The external cause is generally exposure to cold, especially when 
producing repressed perspiration. Its internal or essential cause 
seems to be an abnormal condition of the blood, which contains 
always an excess of fibrine and of uric acid : the latter is probably 
the materies morbi or peccant matter. 

Acute rheumatism commences with the ordinary premonitory 
signs of inflammation, rigors, heat, thirst, restlessness, and anxiety 7 
speedily followed by severe pains attacking the larger joints. These 
pains are ordinarily very severe, following much the course of the 
muscles, and producing such extreme tenderness that the weight of 
the bed-clothes can hardly be borne, and motion of an affected joint 
is intolerable anguish. The swollen joint is usually red and puffy; 
the swelling is, however, more certainly present than the redness. 
The constitution in the mean time shows signs of active inflamma- 
tory fever; the tongue is covered with a white fur; the pulse is 
sharp, bounding, and not yielding readily to pressure ; the urine is 
scanty, and the bowels generally torpid ; the skin, however, is com- 
monly bedewed with an unctuous perspiration, which has a peculiar 
acid odour, which it is difficult not to recognise. The inflammation, 
instead of running the ordinary course of common inflammation, is 
exceedingly erratic, or liable to metastasis, as it has been termed, 
suddenly leaving one part and attacking another: sometimes the 
part to which it transfers itself is an internal fibrous structure, and 
of these the most liable to be attacked is the pericardium ; the sub- 
stance of the heart also is probably liable to be implicated, and next 
to the pericardium, the endocardium, particularly the valves of the 
left side of the heart, is most susceptible. The other membranes — 
the pleura, peritoneum, dura mater, and tunica vaginalis — may also 
be attacked. It is, however, the tendency to metastasis to the heart 
which constitutes the great danger of the disease; not that it is neces- 
sary that the inflammation should leave the extremities that the 
heart should become affected, for the heart affection as commonly 



116 KHEUMATIC INFLAMMATION. 

supervenes without subsidence of rheumatic inflammation in the 
joints as with it, — or even more so. The ordinary termination is 
resolution ; but true rheumatic inflammation never leads to suppura- 
tion or gangrene, nor, when it is in the extremities, to adhesion; 
when, however, it attacks the pericardium or other internal part, it 
runs the same course as common inflammation. Sometimes there is 
a copious effusion of fluid into the synovial capsules and sheaths of 
tendons, especially the capsules of the knee. This difference has led 
to a distinction between fibrous and synovial rheumatism. The true 
acute rheumatism is, however, generally of the former kind, the latter 
being a more sub-acute form, and often a sequela of the acute. 

The external cause is, as has been stated, exposure to cold, and 
repressed perspiration; there are, however, no doubt some persons 
constitutionally liable to this disease, which also seems to prevail 
more in particular seasons than in others ; generally, but not univer- 
sally, when the weather is cold, damp, and variable. The disease 
generally attacks young persons, prevailing most in youth and early 
manhood. After thirty-five it becomes less common ; though cases 
do occur at all ages, and even young children are not exempt. It is 
generally believed that the tendency to afTect the heart is greatest 
before puberty, and some have gone so far as to assert that no young 
persons under that age ever get through an attack of acute rheumatism 
without that organ being more or less involved. 

The robust and plethoric, are also said to be more liable than others 
to attacks of rheumatism ; though the experience of our London hos- 
pitals hardly warrants such a conclusion, since it is a common disease 
amongst the London poor, who are not generally very robust or ple- 
thoric; and it attacks females, and delicate females too no less than 
men. 

The sub-acute rheumatism, to which we have before alluded under 
the term synovial, is often a sequela of the acute, though it may arise 
primarily. It attacks the same structures, and often produces great 
deformity and distortion : the joints become enlarged from the effu- 
sion into the capsular ligaments, and the muscles waste. It is 
perhaps more common to see it affecting the smaller joints than is 
the case with acute rheumatism ; and probably on this account it is 
often known by the name of rheumatic gout, and not without reason, 
for it is perhaps the connecting link between the two diseases. When 
long continued, it produces stiffness of the joints, amounting in some 
cases to perfect immobility, and they are distorted as if actually dis- 
placed This is particularly the case when the disease attacks the 
fingers. 

The above constitute the diseases to which the term rheumatism 
ought to be restricted. The chronic rheumatism or rheumatic pains 
belong to a distinct class; they may indeed have their origin some- 
times in the same causes as true rheumatism, but as the former 
are essentially blood diseases, so the latter are essentially nervine; 
and therefore we shall speak of the so-called chronic rheumatism 
separately. 



DIAGNOSIS. 117 

The diagnosis of acute and chronic rheumatism is generally pretty 
obvious — the severe pains, the swelling, the febrile excitement which 
accompany the former can seldom be mistaken ; yet these are not to 
be implicitly relied upon unless the rheumatic odour be also present, 
since cases have occurred in which the arthritic pains and swelling, 
closely simulating rheumatism, have occurred as the result of irri- 
tation of the nervous centres. In one remarkable case, in Guy's 
Hospital, which closely simulated acute rheumatism, the primary 
disease was inflammation of the cervical portion of the medulla 
spinalis. Cases like this are of rare occurrence, but they are of great 
interest, as showing the possible nervine origin of even acute inflam- 
mation ; and they readily explain how the pains which are so hastily 
included under the term rheumatism may be in reality nervine 
affections. 

The danger of rheumatism as affecting life is in general but little, 
unless it attack the heart or other important internal organ; and, 
therefore, as such an occurrence is always possible, the prognosis 
should be guarded accordingly. As regards the probability of per- 
fect recovery, the same liabilities are to be borne in mind, and there- 
fore the condition of the heart cannot be too frequently or too carefully 
examined. We do not here enter into details which belong more to the 
special consideration of cardiac disease, which will be found elsewhere ; 
but would merely insist upon the importance to be attached to every 
abnormal circumstance affecting the circulation, whether it be mur- 
mur — impulse — or deviation from the natural character of the pulse. 
And as regards any permanent ill effects from rheumatism, we must 
not forget the occasional occurrence of the sub -acute form of the 
disease (which would be more properly termed the chronic), pro- 
ducing the lamentable stiffness, immobility, and distortions already 
alluded to. 

Eheumatism is a disease often resisting the best-selected remedies, 
and apparently running its course unchecked ; so much so, that many 
authors of judgment and experience have expressed their opinion, 
that in most cases it will, in spite of remedies, run a course of five or 
six weeks, and that, notwithstanding many certain and speedy reme- 
dies. There are, however, certain modes of treatment which deserve 
special notice, and some upon which we believe great reliance may 
be placed. Here we would premise that (1) rheumatism is an inflam- 
mation; (2) that it originates in the presence of an excretory matter 
in the blood, produced probably in excessive quantity, through 
defective assimilation, or imperfect oxidation of the products of the 
interaction of the blood and the tissues (owing to which uric acid is 
formed in too great abundance in the extreme circulation, instead 
of urea); and further, (3) that though a blood disease, it neverthe- 
less involves the nerves of sensation and voluntary motion more 
decidedly, if not more essentially, than ordinary phlegmasia, as is 
well pointed out by Dr. Addison, (Elements of Practice of Medicine, 
p. 576.) 

Three prominent indications suggest themselves — (1) to subdue 
the inflammation, regarding it simply as such; (2) to eliminate the 



118 EHEUMATIC INFLAMMATION". 

excretory matter acting as a poison ; (3) to correct the mal-assimila- 
tion, and so prevent the undue formation of uric acid, or at all events, 
promote its conversion into the more soluble matter urea, which is 
more readily carried out of the system. To these may be added the 
specific treatment; and finally, we shall give the plan of treatment 
which we consider deserving the greatest confidence. 

The first indication suggests decided antiphlogistic measures, and 
undoubtedly they are not without their use. Of these the most 
obvious is bleeding; and in a plethoric subject, with a strong pulse, 
a full bleeding at the commencement of the disease often goes a great 
way to arrest its progress, or at all events to render it more amenable 
to other remedies. But the frequent repetition of the bleeding is 
most objectionable: we would advise that it should never be repeated 
beyond a second time, if so often, unless in the case of cardiac or other 
internal inflammation ; since it renders the patient more liable to that 
terrible malady sub-acute synovial rheumatism: it is also contra- 
indicated by the tendency of the disease itself to produce ansemia, or 
defect of red blood, which is favoured by venesection. Purging is 
another antiphlogistic measure of considerable service; but when 
carried to the extent of five or six loose motions daily, it has more 
the character of the eliminating plan of treatment. Antimonials are 
useful in the same way. The great suffering, however, suggests the 
use of opium, which in combination with the antimony, and a little 
calomel, may be regarded as an antiphlogistic means ; and by these — 
the bleeding at first — the antimonials with salines — the opium and 
calomel, with a little additional antimony, the patient may generally 
be carried well through the disease ; but, as Dr. Alison observes, " the 
acute rheumatism cannot probably be much shortened in its duration 
by antiphlogistic remedies." We may also add, that mercury cannot 
be relied upon as an antiphlogistic measure to the extent to which it 
can, in other phlegmasiae; and it is particularly liable to the objection 
that it diminishes the quantity of red corpuscles. 

"We have just spoken of opium, and have alluded to the extensive 
implication of the nervous system in rheumatism ; and towards obvi- 
ating excitement in, or implication of the sentient extremities of the 
nerves in this disease it presents an efficient means ; and opium alone, 
in grain doses, repeated every three hours, will sometimes cut short 
an acute rheumatism in a very few days, but it is hardly safe unless 
combined with evacuants. In the case of a sound subject, a full 
bleeding, a purgative, and the opium treatment will often act almost 
heroically. 

Various specifics have been recommended in rheumatism, of these 
the most conspicuous are bark and colchium; of bark and quinia it 
may be affirmed, that in the acute stage of the disease they are inad- 
admissible, though when the inflammation has been subdued, and the 
pains have at all a periodic character, the bark and soda, or (if there 
be excessive perspiration without mitigation of the symptoms) quinia 
and acids will be very beneficial, though their emploj^ment is more 
appropriate to the sub-acute form. 

Colchicum has, no doubt, great power over rheumatic inflamma- 



TREATMENT. 119 

tion; but it may be doubted whether this is not merely dependent 
upon its power of elimination, though it is also an effective sedative 
to the circulation. It does not, however, generally arrest the rheu- 
matism, unless it act fully upon the bowels or kidneys, producing 
either the loose pea-soup-like motions, commonly known as colchi- 
cum stools, or copious, rather dark urine, or both. If, however, it 
cut short the rheumatism by its simple sedative or antiphlogistic 
power, there is too much reason to apprehend its reappearance in the 
heart; and the belief has certainly gained ground that rheumatic car- 
ditis has increased in frequency with the use of colchicum in the 
treatment of rheumatism. When this drug is used, it ought certainly 
to be administered in combination with some aperient, so as to secure 
a free action of the bowels ; and there is, perhaps, no safer or more 
efficient form than the powder of the cormus ; this should be given 
three or four times a-day with the magnesia and salt draught (9),* 
commencing with about three grains, and gradually increasing the 
dose to five or six. To prevent excessive irritation, a grain of calo- 
mel, with one grain of opium, may be given night and morning. 
This treatment may be continued until either the evacuations above 
noticed have been produced, or the symptoms subside, or there is 
any irregularity in the pulse, which should always be carefully 
watched, as sudden and very dangerous syncope might be the result 
of not withdrawing the colchicum upon the first appearance of this 
symptom. Under this treatment the inflammation will often have 
disappeared in the course of a week or ten days; but there is an 
uncertainty about the action of colchicum, depending partly upon its 
being a cumulative agent in the system, and partly perhaps upon a 
variation in the strength of different specimens, that renders it almost 
impossible certainly to prevent its sudden and uncontrollable action 
as a poison. 

One of the most ingenious methods which has ever been suggested 
for the treatment perhaps of any disease, is the attempt to prevent 
the excessive formation of uric acid, or at all events induce its almost 
immediate conversion into urea, in the extreme circulation. The 
agent selected for this purpose by Dr. Owen Kees, is lemon-juice, by 
the digestion and decomposition of the citric acid in which, he be- 
lieved that oxygen would be supplied, that would, by oxidating the 
uric acid, convert it into urea. He therefore recommended lemon- 
juice to be given in doses, which he ultimately increased to two or 
three ounces, three or four times a-day ; and in a considerable num- 
ber of cases the patient has become convalescent in five or six days. 
It is, however, exceedingly doubtful whether the remedy has pro- 
duced its effect by the chemical change suggested, or as a sedative to 
the circulation; certain however it is, that it has a powerful effect 
of the latter kind, sometimes lowering the pulse to an extent that 
becomes alarming. It ought, therefore, only to be used when the 

* (9) R. Mag. sulph. 31 — gii. 
Mag. carb. gr xv. 
Aq. menth. pip. £x. Misce. 
Ft. haustus. 



120 EHEUMATIC INFLAMMATION. 

patient is robust, and the rheumatism of the well-marked acute 
character, and it is remarkable that such are the only cases which 
commonly do well under its use. The powerfully depressing effect 
of this remedy, and its frequent failure, as well as the fact that car- 
diac inflammation does sometimes arise during its employment, are 
drawbacks to its eligibility for the cure of rheumatism. 

The method of elimination consists in the endeavour to promote 
excretion from the skin, the kidneys, and the intestines. Dr. Todd 
has recommended its adoption in nearly the following form, which 
is certainly by no means an inefficient mode of treatment. Let the 
bowels be freely acted upon, let the patient be strictly confined to 
bed (which of course is assumed to be done, whatever method be 
employed), let the affected extremities be carfully wrapped in cotton 
wool, and over each a sheet of gutta percha may be placed, and let 
the annexed combination be given every four hours (10).* 

The following plan of treatment, which is a modification of this 
method of elimination, is that which the author has found to be in 
general the most certain, as well as least liable to the objections 
which have been noticed as applying to the others. Let the bowels 
be freely acted upon by the purgative draught (2),f with the addition 
of about half a drachm of the compound tincture of colchicum, and, 
the patient being confined to bed, let the cotton wool be applied as 
above, and the patient be put upon the use of the draught (11) J every 
four hours. Upon this simple treatment, the patient will often be- 
come convalescent within a week, about which time, the urine will 
generally throw down an abundant deposit of urates. This plan of 
treatment has the advantage that it may be continued should any 
internal inflammation require the use of mercury, and that it is also 
admissible when the disease assumes the more chronic or sub-acute 
form, which is not the case with the lemon-juice. 

The sub-acute or synovial rheumatism when it follows as a sequela 
of the acute disease, and comes early under treatment, will in most 
cases yield to a course of the acetate and nitrate of potass, or in cases 
where the debility is considerable, the same quantity of bicarbonate 
may be substituted for the nitrate ; and, provided there be no inflam- 
matory symptoms, the infusion or decoction of cinchona may be used 
as a vehicle, to which in a short time the compound tincture may be 
added. In still more chronic cases, especially if there be much per- 
spiration, the quinia and sulphuric acid may be employed: in very 
chronic cases with much pain, the accompanying form is a good one 

* (10) R. Pulv. opii, 

Pulv. ipecac, aa gr. ss. 
Pot. nitrat. gr. iv. Misce. 
Ft. Pulv. 

f p. 104. 

t (11) B Pot. acetat. 5 ss.— £ ij. 
Pot. nitrat. gr. v. — x. 
Tinct. opii, tt^ iv — viij. 
Decoct, hordei, ^ iss.— ^ ij. Misce. 
Ft. haustus. 



GOUT — ACUTE. 121 

for the employment of the quinia. (12)* When the pain undergoes 
aggravations at night, whether we have or have not reason to sus- 
pect a syphilitic taint, though still more in the former case, the iodide 
of potassium is a most valuable remedy. In general two grains three 
times a day, will be a sufficient dose, but it may be increased to three 
or four. 

The functions of the skin should however be steadily maintained, 
and, when not excessive, encouraged, and therefore the Dover's 
powder, or the combination of opium with nitrate of potass, given 
above, should be used at night, and it is chiefly by its diaphoretic 
action, that guiacum has obtained some confidence in the treatment 
of chronic rheumatism; but whilst we endeavour to promote the 
functions of the skin by internal remedies, we may with advantage 
employ warm baths : and the natural hot- waters, as those of Bath, 
are often serviceable. 

Where there is much effusion into the joint, blisters will often 
promote its absorption, and the application of the tincture of iodine, 
until some irritation of the skin is produced, is a very useful adjuvant. 
The iodine may sometimes be used with advantage in a still more 
powerful way, namely, by soaking a piece of lint in the tincture, and 
then allowing it to remain some hours upon the affected joint. 

When the chronic rheumatism is of long standing, or when it has 
come on without any previous acute attack, it is one of the most in- 
tractable maladies with which we have to do, and the distortions 
which it produces, are often permanent. 



GOUT. 

Closely allied to rheumatism, yet distinct from it, is gout — a disease 
which was one of those the best known to the ancients, under the 
term of podagra or foot-pain, and for which various more scientific 
names have been suggested, but of which none is less objectionable 
than that by which it is popularly known. Gout has been divided 
into endless varieties by different authors; but perhaps the best, 
because the simplest, classification, is the division adopted by Dr. 
Copland into acute gout, chronic gout, and irregular gout. 

An attack of acute gout is generally preceded by symptoms of 
gastric derangement and incipient pyrexia. These consist of rest- 
lessness — drowsiness, though with want of refreshing sleep — depres- 
sion of spirits — and general lassitude: at the same time, there are 
pains or flatulent distension of the stomach — cardialgic pains, with 
sometimes acid eructations — now and then a sense of coldness in the 
epigastrium — the bowels are irregular, generally costive, though 
sometimes there is looseness ; — the tongue is also coated and the urine 
turbid. These premonitory symptoms, however, vary in different 

* (12) R Quiuioe disulphat. gr. i. — ij. 

Ext. colchici acetici, gr. £ — gr. ss. 
Ext. conii, gr. iij. 
Ft. Pil. ; to be given three times a day. 



122 GOUT. 

individuals, so that one has one peculiar feeling before an attack of 
gout, and another another. 

Generally, after symptoms of the above character, of two or three 
weeks' duration, though in some few instances without any previous 
sign whatever, the patient is awakened some time after midnight — 
commonly about two in the morning — by severe pains in one of the 
smaller joints, often the ball of the great toe. The pain is of a severe, 
burning, throbbing character, attended by stiffness. These symp- 
toms increase, and the burning and throbbing become most intolera- 
ble ; the actual temperature of the surface becomes much increased, 
and the occasional shooting pains are such as to suggest the idea of 
the joint being pierced by hot wires, or torn by pincers; the affected 
part is exquisitely tender, so that the slightest touch or most gentle 
movement cannot be endured. With this severe suffering, there is 
of course great restlessness, and considerable fever, all which symp- 
toms generally go on increasing till about six or seven in the morn- 
ing, about which time perspiration begins to break out, and the 
severity of the pain to subside, so as in the milder cases to allow the 
patient to obtain some sleep. The appearance of the part shows 
active inflammation; the integuments are red and swollen, often 
shining, and the veins preceding from it remarkably distended. 
The pains generally continue mitigated throughout the day, but 
again return with equal or even increased severity after midnight, 
and continue till six or seven in the morning, when they again abate ; 
in very severe cases, however, there may be no remission for several 
days. As in all other inflammations, the general symptoms vary 
according to the intensity of the inflammation, and the constitution 
of the patient; they are, however, essentially, those of fever, with 
disorder of the digestive organs; there being, in addition to those 
already stated, a pink lateritious sediment in the urine, which is 
sometimes also coloured with bile, whilst the stools show either a 
deficiency of bile, in being drab-coloured and claj^ey, or otherwise 
they are green or blackish, from a vitiated state of that secretion. 
The tongue is furred or loaded, and the papillae commonly erect. 
The pulse is variable, generally frequent and hard, especially in a 
first attack, and when the disease is fully developed in the extremity. 

The duration of a first attack of gout varies from two to ten or 
twelve days, the oedema generally continuing after the subsidence of 
the inflammation, and there is desquamation of the cuticle with 
much itching. The disease sometimes reappears in another extremity 
— generally the other foot — and runs the same course, often with 
greater severity. After the subsidence of the attack, the patient 
usually feels in much better health than he probably has done for 
months, or it may be years, before; but notwithstanding this ap- 
parent benefit, the disease is almost sure to return, though the in- 
terval may vary according to the constitutional liability of the 
patient, and the pains which he may take to avoid those circum- 
stances most likely to induce it. Thus, with ordinary care, after a 
first attack, three or four years of immunity may be hoped for ; but 
the intervals become shorter and shorter, and what is worse, the 



CHRONIC — IRREGULAR. 123 

attacks longer and longer, so that sometimes the gout becomes not 
only an annual visitant, but one whose absence is only of a few 
months' duration. 

After each of the few first attacks, the swelling entirely leaves the 
joints, which recover their former mobility, but when the disease has 
recurred several times, the joints become permanently swollen, weak, 
and in some instances entirely lose their capability of moving ; owing, 
too, to the vitiation of the secretion of the synovial fluid, there is a 
grating sensation produced upon bending the joints. Another effect 
is the deposition of what are familiarly known as chalk-stones (from 
their close resemblance to that substance) around the joints, filling 
up the areolar tissue, and lying for the most part immediately under 
the skin, one effect of which is entirely to destroy mobility. These 
consist of urate of soda, which is deposited in the first instance in a 
semifluid state, like mortar, and which subsequently hardens by the 
absorption of the fluid ; the skin covering these concretions some- 
times dies, and falls off, leaving them exposed, so that some persons 
in whom they have occurred have been known to be able to write 
with their knuckles as with chalk. 

There is, as we have said before, a chronic form of the disease, in 
which the inflammation assumes a more lingering and chronic cha- 
racter, the pains are irregular and wandering, the redness less vivid, 
and the swelling of the part more permanent ; there is at the same 
time considerable constitutional disturbance, disorder of the digestive 
organs, languid circulation, and that irritability of the nervous system 
which belongs rather to debility than to active inflammation. 

This chronic gout is, in most instances, a consequence of one or 
more acute attacks, though sometimes it is itself the primary affec- 
tion, and seems to be the effect of the presence of the gouty dia- 
thesis in the system, with want of power sufficient for sthenic action. 
In the latter form it appears to belong more especially to those who 
have inherited the tendency, but whose habits of life have not been 
such as to call it into activity ; and accordingly it has been observed to 
be more common among women than among men. It is remarkable, 
too, that in this form of gout the ball of the great toe is not so com- 
monly affected, but the disease is more apt to attack the wrist or 
ankle, so that in the slightest cases there is much difficulty in walk- 
ing. The pains often follow the course of the nerves, and it is by no 
means improbable that this form has much more of a nervine cha- 
racter than has the acute. 

We have already alluded to the possibility of the existence of the 
gouty diathesis, without its manifesting itself by any active inflam- 
mation — to the fact, in short, that a person may be gouty without 
having the gout. It is probably this circumstance that gives rise to 
the most dangerous phase of the disease, namely, its locating itself 
in some vital organ, constituting the irregular govt, otherwise de- 
scribed as misplaced, retrocedent, metastatic, or masked gout. Thus 
a person may have had some of the premonitory symptoms of an 
attack of gout, though in some instances hardly sufficient to attract 
much attention or divert him from his ordinary pursuits, when he is 



124 GOUT. 

suddenly seized with vertigo, or it may be some more urgent symp- 
tom of cerebral disturbance, as loss of consciousness or hemiplegia ; 
— or the heart may become the object of attack, and syncope, palpita- 
tion, or irregular intermittent pulse may be the consequence ; — but 
perhaps there is no organ so likely to be assailed as the stomach and 
the parts immediately connected with it, when there is heartburn, 
sickness, flatulence, acrid eructations, and gastrodynia — sometimes, 
however, the symptoms are much more severe — the patient is at- 
tacked by cramplike pains in the epigastrium, shooting thence into 
the upper extremities, or he may be seized with a cold death-like 
sensation at the pit of the stomach, as if a sheet of ice were laid there, 
the pulse becoming rapidly very feeble, and death from syncope 
being apparently imminent. Sometimes, again, the liver or the 
kidneys may be affected ; in the former case, there is pain in the 
region of the liver, the secretion of which becomes either suppressed 
or of a morbid character ; in the latter, there is violent pain in the 
region of one or both kidneys, the urine being in some instances 
suppressed, in others highly albuminous ; in others again loaded with 
uric acid or urates. What is remarkable is that these symptoms, 
sometimes when most urgent or alarming, will suddenly subside 
upon the appearance of gout in one of the extremities. In other 
cases, however, this process is reversed, the gouty inflammation sud- 
denly subsiding in the extremity, and being followed, after an un- 
certain interval, by some very grave symptoms of disease in a vital 
organ. It is this which has received the name of retrocedent gout. 

Concerning the pathology of gout, there has been much diversity 
of opinion. The earlier writers among modern physicians, as well 
as the ancients, considered it as the effect of a "peccant humour," 
which was endeavouring to throw itself off from the surface and 
extremities. Cullen again believed the seat of the disease to be in 
the nervous system, though he failed in his endeavour to prove it to 
be so: later authors have however recurred to the doctrine of the 
ancients, and are pretty well agreed that the cause of the more ob- 
vious symptoms is to be found in the presence in the blood of a 
morbid poison, which is of a cumulative character. This materies 
morbi is most likely a product of the secondary assimilative process, 
nearly allied to uric acid, if it be not identical with it : the uric acid 
in the chalk-stones, and the frequent relief of gout by the excretion 
of a large quantity of uric acid gravel by the urine appear to render 
this supposition highly probable, as does also the fact that luxurious 
living, with the use of a large poportion of animal food, is conducive 
alike to the uric acid and the gouty diatheses. 

The circumstance of this materies morbi locating itself generally in 
particular parts, or organs, though sometimes assailing others with equal 
violence, may be not unsatisfactorily explained by the suggestion of 
Dr. W. Budd, in the paper before alluded to, viz., that these poisons 
have an elective affinity for certain tissues or organs or parts of the 
body, and that when a morbid poison has been generated in the 
system, it will primarily affect that particular part for which it has 
this affinity, and that it is generally not until this particular part has 



PATHOLOGY — PEOGNOSIS. 125 

been saturated that the poison attacks that which stands next in 
order in the degree of affinity. It may, however, be repelled from 
the first part by some circumstance which prevents its active de- 
velopment ; and conversely, when it has attacked some deep-seated 
part, it may be transferred to a part to which it has ordinarily a 
greater affinity, by the removal either of the condition which pre- 
vented its development in the latter situation, or of the irritation 
which attracted it to the former. The conditions upon which this 
peculiar elective affinity of the poison of gout, as well as other morbid 
poisons depends, are not in any way apparent; but it is obvious, 
from every-day experience, that it may be disturbed by disease, 
febrile excitement, and other causes of change in the vital actions, it 
being well known that gout will often attack a joint in which there 
has previously existed an inflammation, as from a sprain or other- 
wise, and even the cicatrix of an old wound. 

It has been truly observed, in reference to these views, that they 
assume a modified humoral pathology as essential to the elucidation 
of otherwise inexplicable phenomena;* but it must not be forgotten 
that nervous influence may also control this affinity, and that there 
can be no doubt that in many cases it does so. 

It is not, however, intended to imply by what has been said that 
lithic or uric acid is the alone or efficient cause of gout; for if this 
were true, we should always have gout when uric acid is in abun- 
dance, and never have gout without it; whereas the presence of the 
one without the other, especially of uric acid without gout, is a matter 
of every-day experience. Upon what the gouty diathesis, or suscep- 
tibilit} r , depends we know nothing; it manifests itself in the system 
by an affinity for the gouty poison (uric acid it may be) in different 
parts. If this diathesis be such as to produce an affinity of extraor- 
dinary intensity, there may be a local excess of this substance, 
without any such excess, or even with a deficiency, in the system at 
large, just as there may be a local hyperemia, although the general 
state of the system may be angemic. This explanation of the difficulty 
is merely suggested as possible, not enunciated as certain; it never- 
theless derives confirmation from the recent observation of Dr. Gar- 
rod that uric acid is present in the serum effused when a blister has 
been applied over a joint affected with gouty inflammation. 

Notwithstanding the obscurity which attaches to the pathology of 
gout, it has been fully ascertained that it observes certain laws, viz., 
that it is hereditary ; that the tendency in any individual is promoted 
by luxurious living and sedentary habits; that it more commonly 
attacks the male than the female sex ; that it rarely makes its appear- 
ance in a subject under the age of five-and-thirty. 

The only diseases with which acute gout is liable to be confounded 
are acute rheumatism and common inflammation affecting the joints. 
From the former it may be distinguished by its rarely affecting more 
than one joint: — by the age of the patient, which is in most eases far 
be} r ond that in which rheumatism is most frequent; indeed, we 

* Brit, and For. Medical Review, vol. sv. p. 150. 



126 TREATMENT OF GOUT. 

might even say that in this respect where rheumatism ends gout 
begins. In gout, there is more evidence of disorder of the digestive 
functions; in rheumatism, of acute inflammatory fever. Common 
inflammation of a joint, again, may be distinguished from gout by the 
absence of intermission, the difference in the constitutional disorder, 
the character of the pain, and the state of the urine. Chronic gout 
again may be distinguished from chronic rheumatism by most of the 
circumstances just noticed — by the greater oedema, whereas the swell- 
ing in chronic rheumatism is in the bursas and synovial capsules, — 
and by the tendency to form "chalk-stones." 

The prognosis of gout, as must appear from what has been said, 
should at all times be guarded. Whilst the gout remains in the 
extremities, there is no risk to the life of the patient; but it is upon 
its liability to leave the extremities that the danger depends; and, 
notwithstanding that many persons find their health much better 
after an attack of gout than before it, and some even long for it as a 
means of clearing the system of other disorders, yet experience proves 
that a liability to gout is a source of danger, and all the assurance 
companies consider the life of a person who has been the subject of 
gout, so far endangered by it as to entitle them to demand an 
increased premium. 

The treatment of gout divides itself into that which is applicable 
to the paroxysm, and the preventive or prophylactic, designed to 
correct the gouty diathesis. 

By the earlier physicians, and until lately, the cure of gout was 
left, like that of rheumatism, to flannel, time, and patience ; but there 
is in the minds of the greater number of practitioners a feeling that 
something should be attempted, and that our extended knowledge of 
the nature of the disease should be productive of some more efficient 
practice. If the views which were suggested as arising from the 
chemical agency of lemon-juice in the cure of rheumatism had been 
strictly correct, that substance ought to be still more efficacious in the 
treatment of gout ; but this remedy has apparently little or no power 
over the latter disease. Of all medicines colchicum is undoubt- 
edly that which approaches most nearly to a specific for gout, though 
its use is not without danger, and requires the greatest caution in the 
administration. Colchicum has, it is true, a decided influence on a 
paroxysm of gout; the pain which had before been intense some- 
times ceasing almost entirely after the use of the drug has been con- 
tinued for two or three days; and it has been ascertained that this 
ingredient enters largely into most of the popular nostrums for gout; 
but it is probable that its influence is greater in counteracting the 
local effects of the poison than in preventing its formation or in 
eliminating it from the system ; and therefore, if precautions be not 
taken to insure one of the two latter results, the disease which has 
subsided in the extremity is very apt to reappear in its most dan- 
gerous form in some important viscus. Colchicum, then, unless it act 
as an eliminant, either by the skin, the bowels, or the kidneys, is a 
palliative rather than a remedy for gout. 

It should always be borne in mind in the treatment of gout, that 



TREATMENT OF GOUT. 127 

not only may the inflammation be driven to an internal part by 
checking it in the extremity, without at the same time eliminating 
the disease from the system; but also that it may be drawn or 
attracted to it by exciting irritation in that situation ; and therefore, 
since colchicum acts, as Dr. Watson justly observes, as an anodyne 
in the gouty paroxysms, it may have the former effect; and as it is 
also apt to be a powerful excitant to the alimentary canal or kidneys, 
it may in the latter way prove dangerous. 

The best and perhaps the safest treatment of gout consists there- 
fore in the combination of the colchicum with means which may 
promote elimination without powerfully affecting the excreting 
organs. 

The patient should be confined to bed, and the affected extremity 
wrapped in flannel or the cotton wool, and a few grains of blue pill 
may be given at bed-time, with three or four of James's powders and 
the aperient draught (13)* administered the following morning; after 
this the saline recommended in rheumatism, but with about half the 
quantity of the salt, may be administered two or three times a day, 
with at first about ten minims of the vinum colchici, or the form 
(14)f may be used instead of it. If the bowels are torpid, the blue 
pill and cathartic draught may be repeated; or if the motions are 
deficient in bile, without the bowels being confined, the blue pill 
alone may be used. 

After the pain and inflammation have subsided, what Dr. "Watson 
calls alterative doses of colchicum may be employed; about five 
minims of the wine being given three times a day (15) J. 

The treatment of the gouty diathesis, that is of a gouty patient 
between the paroxysms, must be chiefly dietetic. Moderate living, 
and regular moderate exercise, will in many cases, if steadily adhered 
to, procure a perfect immunity from future attacks ; and if a necessity 
for stimulating drinks have not been established by their long-con- 
tinued use, it will, as Dr. Watson observes, be worth any young 
man's while to become a teetotaller; though it is otherwise with the 
old, and those who have been inured to what is miscalled good living, 
or whose constitutions have been impaired by this inveterate disease; 

* (13) R. Mannae, 3 iss. 

Yin. Colchici, n\^ xx. 

Inf'us Sennce, co. 3; x. 

Pot. Tart. 3 ij. 

Tiuct. Cardom. co. 3 i. Ft. ITaust. 

f (14) R. Totassre Acetat. ►} i. 

Bicarb, gr. x. 

Yin. Colchici, Tr^ x. 
Decoct. Hordei, 3 iss. 
Ft. Haust. 

t (15) R. Mag. Cart), gr xij. 

Tinct. Cardom. co. 5 ss. 
Vin. Colchici, Tt^ V — x. 
Aquoe purte, 3 x. 
Ft. Haust. 



128 TREATMENT OF GOUT. 

for if their powers be enfeebled by reducing their mode of living, 
the debility thus induced renders them only the more susceptible; 
though in all a single debauch may bring their enemy suddenly 
upon them. Gout in the stomach, whether it attack the organ by 
retrocession, or whether it arise there primarily, is always attended 
by imminent danger. It does not, indeed, appear that the affection is 
of an active inflammatory character, since it is most commonly relieved 
by stimulants, and threatens death by syncope; it is probably in the 
form of an asthenic hyperemia. When the symptoms of this affection 
present themselves, our first business should be to ascertain if any 
indigestible food has been taken; since, as Dr. Watson remarks, gout 
in the stomach may turn out to be pork in the stomach. Yet it is 
possible, upon the principles already laid down, that the latter may 
excite the former. When there is reason to believe that such matters 
are present, an emetic should be administered; and afterwards the 
magnesia draught (15), with about ten minims of laudanum; if this 
fail, a glass of brandy will sometimes allay the pain completely. 



AUSCULTATION. 129 



IX. 

AUSCULTATION. 

Before we commence the consideration of the diseases of either 
of the three great cavities of the body, as they are termed — namely, 
the cranium, the thorax, and the abdomen — it may be well to call to 
mind that each of the viscera contained in any one of these cavities 
is differently circumstanced from those in either of the others, in 
regard to the degree in which they are accessible to our examination 
of their physical condition. The viscera enclosed within the cavity 
of the cranium, are screened by its bony walls from our manipula- 
tion, and, therefore, we are confined in our endeavours to ascertain 
the seat and nature of any disease which may be going on within 
them, to the use, first, of those general, or as they are termed, consti- 
tutional signs by which we judge of the existence of inflammatory or 
other disease, and secondly, of the disturbance or non-performance of 
the function (the Icesa partis functio) of any particular part or organ ; 
but we are unable to appreciate, and consequently to derive any 
assistance from the physical changes in that part, which the disease 
may have induced. 

The viscera of the abdomen again are contained in a cavity, the 
walls of which, for at least two-thirds of their surface, yield readily 
to the pressure of the hand, and, consequently, enable us to detect 
changes which disease may have produced in the size or hardness of 
their contents. We are also enabled, from the same circumstances, 
to detect any tenderness which inflammation may have excited, and 
thus obtain further important information as to the nature, the seat, 
and the extent of the disease ; and by the use of percussion to detect 
any variation in the solidity of the viscera, a matter of great import- 
ance in regard to the hollow alimentary canal. 

The viscera of the chest again are differently circumstanced in the 
above respects from those of either of the other cavities. They are, 
indeed, excepting where its cavity is separated, by the diaphragm, 
from the abdomen, and at the comparatively small space above, 
included between the two first ribs, the vertebras, and the first bone 
of the sternum, enclosed within walls rendered rigid by bone or car- 
tilage, and, therefore, withdrawn almost as completely as the brain 
from every attempt to determine any change in their physical con- 
dition by means of the hand: this is, perhaps, one reason why there 
was, till within the last thirty years, the greatest difficulty in deter- 
mining not only the seat or character, but often the very existence of 
disease within the chest. Since, however, the happy thought which 
had before suggested itself to Avenbriigger (and there is some ground 
for suspecting even to Hippocrates), of applying another souse, that, 
namely, of hearing, to the investigation of disease, was realized and 
made practically available by Laennec, a complete revolution has 

9 



130 AUSCULTATION". 

taken place in the comparative accuracy of our diagnosis of diseases 
of the viscera of the chest, and those of the other regions of the body ; 
so that we are now able to diagnose their nature and seat with an • 
approach to certainty, which we have yet to attain in regard to dis- 
eases of the head or the abdomen. 

For although the viscera of the chest are beyond the reach of the 
sense of touch, they are peculiarly accessible, so to speak, to that of 
hearing. The lungs, which occupy by far the larger portion of the 
cavity of the chest, have, in their healthy state, a loose spongy tex- 
ture, the cells being filled with air; the consequence of this is, that 
when a moderate blow or tap is given upon the ribs, a sound is 
elicited very different from that which would be heard if there were 
a solid body in their place : the healthy chest has, in fact, over a 
great part of its surface, a certain resonance upon percussion, the 
absence or noticeable diminution of which is inconsistent with health ; 
for the lung may be rendered solid and impervious to air by disease ; 
or it may be displaced and compressed by fluid, and thus the reso- 
aance of the chest, when percussed, is diminished or obliterated; or, 
on the other hand, the cells may be preternaturally distended with 
air, or, by a rupture of the pleura, air may find its way between the 
lung and the ribs, and thus a preternatural or morbid degree of reso- 
nance may be imparted. We see thus upon what principles the 
sound elicited by percussing or striking the chest may be made to 
assist ns. 3&b this is not the only application of the sense of hearing 
to the investigation of the diseases of the chest, or even the most 
useful one; for ike viscera of this region of the body, whilst they 
perform their healthy functions with admirable precision and regu- 
larity, accompany their action by certain well-known sounds, which, 
to the ear of the practised listener, tell a tale of health and order. A 
soft flowing sound may be heard as the air passes through the bronchi 
to distend the cells of the lungs, and the filling of these cells as the 
air reaches them, is attended by a whispering murmur. The cease- 
less swinging action of the heart too has its music. The contraction 
of this mainspring of the circulation, together with the closure of the 
aurico-ventricular valves which attends it, causes a softish, though 
prolonged sound, whilst the closure of the sigmoid valves of the 
great arterial trunks which immediately follows the completion of 
the systole, and accompanies .the diastole, has its shorter and sharper 

one. 

Kow it needs hardly a moments consideration to perceive that if 
the bronchial tubes be narrowed or widened by disease, or if they be 
obstructed by the accumulation of an excessive secretion, or if the 
lungs lose their spongy texture, and their cells become obliterated, 
or if they be unduly distended, or lose their elastic contractility, or 
if caverns be formed in the substance of these organs, or if fluid or 
plastic effusion, or air, find its way between them and the walls of 
the chest, these sounds must be greatly altered or obliterated, or new 
and totally different ones must be produced. Again, as regards the 
heart, it is equally evident that if its valves be imperfect, or if there 
be any great disproportion between its different cavities, or between 



AUSCULTATION. 131 

any one of these and the orifice by which it discharges its blood, or 
if the texture of the pericardium be so changed that the organ cannot 
play smoothly in its serous capsule, its rhymth must be deranged, its 
sounds altered, and new and unnatural ones must be heard. We see 
then the reason of the practice of auscultation or examing by the ear 
the condition of the organs of the chest. 

We now proceed to describe briefly how this examination is to be 
conducted, premising, however, that any description which may here 
be given is intended only to make what follows more clearly intelli- 
gible ; that the repeated examination of the healthy chest is within 
the reach of all; and that if it be conducted upon a few simple and 
intelligible principles, it will quite supersede all lengthy and compli- 
cated descriptions. 

Of the sounds which accompany the action of the heart and lungs 
in health, no description can give a very accurate idea ; but they may 
be fixed in the memory by repeated observation; and this having 
been done, they will form a standard wherewith to compare the new 
and altered ones which present themselves in disease. As for the 
latter, it has been found expedient to represent them by certain 
words, supposed to be descriptive of the sound in question; and 
these words will be used in their generally-received acceptation, so 
far as that can be ascertained, care being taken to avoid the needless 
encumbering of the subject with an obscure phraseology. We shall, 
however, forbear giving any description of these terms, or of the 
phenomena which they represent, until we come to treat of the dis- 
eases in which they occur ; knowing that the best explanation of the 
morbid sounds is to found in the diseased changes of structure or 
function which give rise to them ; and believing that the rational 
study of disease of the chest has been rendered needlessly difficult, 
if not repulsive, by the attempts to make a separate art of the inter- 
pretation of the acoustic phenomena which accompany disease, and 
to make the art obscure by encumbering it with semibarbarous 
technicalities. 

Many authors have thought it expedient to map out the chest into 
different regions for the purpose of more accurately locating morbid 
changes or signs. As, however, the chest is provided with natural 
lines of demarkation, such artificial division appears to be unneces- 
sary, and upon the whole rather an embarrassment than an aid to 
the learner, whilst the mind of the more practised auscultator will 
always associate any portion of the surface of the chest with the 
parts beneath it, too readily to require any such artificial boundaries. 

Where the condition of the patient and other circumstances allow 
it, it is desirable that he should be seated in a chair, in a semi-erect 
or slightly-inclined position, and then (when the patient is a male 
and where there is no risk from exposure to cold), after the clothes 
have been removed as low as the waist, to proceed to investigate the 
anterior part of the chest. In the female subject, the delicacy of the 
patient may always be consulted by throwing a shawl or some other 
covering over the shoulders, and this so as to leave bare only the 
small space which we wish to examine at one time. The first thing 



132 PEECUSSIOK. 

in doing this should be to observe carefully the movements of respi- 
ration, comparing by the eye the relative mobility of the different 
ribs, and making a more special comparison between that of the 
corresponding ribs on the opposite side. This is a point which 
cannot be too carefully insisted npon. This mobility should be still 
further tested by placing the hand on each side of the chest in differ- 
ent situations respectively corresponding to each other ; thus calling 
in the sense of feeling to the aid of that of sight. The hand should 
also be laid upon the abdomen, and its movements observed, in order 
to ascertain whether the action of the diaphragm in respiration is 
excessive or defective. It is not amiss to test the expansion of the 
chest upon inspiration by a measure drawn round the breast; the 
expansion of the chest thus measured should in the adult male be 
an inch and a half. 

The next step may be to examine the chest by percussion. Now 
percussion is of two kinds, immediate, that is, by striking directly 
upon the chest, without the intervention of any other substance 
between the integuments of the patient and the fingers of the operator 
— and mediate, that is, by placing some substance, as a disc of India- 
rubber or ivory, upon the chest to receive the stroke of the operator ; 
this substance is termed a plessimeter. It is true, indeed, that 
mediate percussion is upon the whole less disagreeable to the patient, 
and more satisfactory to the observer; but the best plessimeter will 
be found to be the first, or the first and second fingers of the left hand ; 
and the best percussor the first and second or first three fingers of 
the right hand curved and brought close together, so that not one of 
their extremities shall project beyond the rest. The fingers of the 
left hand should be laid flat upon the chest, and always at the same 
inclination to the ribs ; the best method will generally be to place 
them across the ribs at an angle of about 45°. The tap or stroke 
given to them should be a moderately sharp and brisk one, the 
fingers with which the stroke is given not being allowed to remain 
in contact with those which receive it sufficiently long to deaden the 
sound, which they will of course do, if allowed to rest there, by 
checking the vibrations upon which its clearness depends. These 
precautions being observed, the percussion may be practised, com- 
mencing with the space immediately under the clavicle on either 
side, and then proceeding in the same manner with the corresponding 
space on the other side, so as to institute a comparison between the 
resonance of the two. In addition, however, to these precautions, it 
should be remembered that independently of disease, there are several 
circumstances which tend to increase or diminish the resonances of 
the chest, and that in health the resonance varies in different parts of 
the same chest. 

Thus the resonance of the chest is greater in lean than in fat per- 
sons. In the old, again, the increased rigidity of the cartilages, from 
the greater quantity of ossific matter contained in them, has the effect 
of diminishing the elasticity of the skeleton, and, to a certain extent, 
diminishes the resonance; though this effect is often more than 
counterbalanced by the less quantity of fat, and even muscles, on 



OF THE RESPIRATION". 133 

the walls of the chest, and by the enlargement of the air-cells, 
whereby the resonance is increased. Again, the resonance of differ- 
ent parts of the chest varies according to the quantity of muscle 
overlaying each. Thus the regions of the scapula and the pectoral 
muscles are duller on percussion, and the axilla and margin of the 
middle portion of the sternum (on the right side) are the most 
resonant. There are, however, differences as regards the contents of 
the different parts of the thorax which materially affect the reso- 
nance, and which it is still more important to remember; thus the 
chest contains, besides the lungs, the heart and large vessels, the 
former of which is in contact with the interior surface of the chest 
through a space of nearly an inch in diameter. Over the correspond- 
ing portion of the chest, and some way beyond it, owing to there 
being only a thin layer of lung interposed between the heart and 
ribs, that is to say, over the cartilages of the fifth and sixth rib, in 
the space between them, and from the middle bone of the sternum 
for about an inch and a half leftwards, the sound is dull. The reso- 
nance is also defective over the false ribs on the right side, owing to 
the proximity of the liver ; and in children, owing to the liver being 
proportionately larger: and sometimes in females, owing to the per- 
nicious habit of tight lacing, this dulness extends as high as the sixth 
or even the fifth rib. On the left side, again, in the same situation, 
we have often a great variation in the resonance, and that taking 
place in a short time in the same individual ; thus the stomach may 
be distended by gas, and rise higher than usual, the effect of which 
is to give rise to a peculiar ringing sound, or, on the other hand, it 
may be filled with liquid, and thus diminish the resonance in the 
same situation; as a general rule, however, the lower part of the 
chest is duller on the right than on the left side. 

The exploration by means of the sounds elicited by percussion is, 
in fact, a species of auscultation or listening; but there is another 
mode of listening of perhaps even greater importance than the former, 
which is termed, par excellence, auscultation, and that is, by listening 
to the action of the various viscera of the chest. 

It needs hardly a moment's reflection to perceive that if a large 
bronchial tube be closed, the respiratory murmur will cease in the 
corresponding portion of the lung; and that the same thing must 
happen if the lung, or a portion of it, be rendered irrespirable by the 
filling of its cells by morbid deposits, or by its being compressed, by 
air, by fluid, or by solid tumours. But, without being silenced, the 
sounds of respiration are apt to be very much altered by disease ; 
they may be rendered louder than natural owing to undue activity 
of a portion of the lung, in which case the respiration is said to be 
puerile, from its resemblance to the breathing of children. Again, 
they may be too faint, as is the case when the cells are over-dilated, 
or when there is partial obstruction of a large bronchus. Again, the 
respiratory murmur may be altered in character rather than in inten- 
sity, as when the breathing becomes hissing, or, as it is termed, sibi- 
lant, by narrowing of L the extreme ramifications of the bronchi from 
swelling of their lining membrane ; or the soft whispering murmur 



134 ASCULTATION. 

may be converted, by change in the walls of the cells, into a fine 
crackling sound termed a dry crepitation. Again, in the case of the 
heart, if there be any great change in the size of its cavities or the 
thickness of its walls, the sounds which accompany their contraction 
and the discharge of their contents will be likewise changed ; and if 
the valves be much altered in structure there will be some modifica- 
tion of the sounds which attend their closure. 

The above, however, is not all, for disease may occasion new sounds 
as well as the alteration of the natural ones; it, in fact, has its own 
proper sounds as well as health. Thus the secretion which lines the 
bronchial tubes is not, in health, of sufficient quantity to cause any 
sound by its being disturbed by the passage of air through them; 
but when this secretion becomes excessive in disease, its agitation, 
both in inspiration and expiration, gives rise to a sound resembling 
that which would be produced by blowing through a tube partly 
filled with fluid, as water thickened with mucilage, which sound 
will, of course, be modified according to the size of the tube, and the 
quantity, and thickness or viscidity of the fluid. In this manner are 
produced the different sounds termed rattles, to be hereafter specially 
described. 

Again, there are sounds termed ronchi, which may be sibilous or 
hissing — sonorous — cooing — the result of contraction or dilatation of 
the tubes; as well as a modification of these, termed cavernous res- 
piration, from the air passing in and out of a large cavern or hollow, 
however formed. These caverns, when partially filled with pus or 
mucous, give rise to a species of rattle termed gurgling. The passage 
of air through the bronchial tubes is not to be heard in health, except 
just below the sterno-clavicular articulation; but when the lung is 
condensed by disease, or pressed upon by fluid, it becomes audible, 
and we hear what is termed bronchial respiration. Mucous crepita- 
tion, again, is a modification, by fluid in the smaller tubes of the 
affected portion of lung, of the crackling or crepitation already 
described. These sounds, and others which are varieties or exag- 
gerations of them, will be more clearly understood hereafter, when 
we come to treat of the diseases in which they are produced, so that 
an analysis of them in this place would be premature. We may, 
however, here remark that we have — 

(1.) Sounds of respiration, modified by disease of the part where it 
is heard, as coarse or harsh respiration — or by that of other parts, as 
puerile respiration. 

(2.) Sounds which may exist in health, but only become audible 
on the surface of the chest by change in the conducting power of the 
surrounding tissues, as bronchial or tubular breathing, and perhaps 
also the expiratory murmur. 

(3.) Sound produced by changes in the walls of the tubes, as 
ronchi. 

(4.) Sounds produced by changes in the contents of the tubes, as 
rattles. 

(5.) Sounds produced by the formation of new hollows accessible 
to the air, as cavernous sounds. 



OF THE VOICE. 135 

(6.) Sounds produced by changes in the structure of the cells, as 
dry crepitation and wheezing. 

(7.) Lastly, we have the sound produced by the motion of two 
surfaces of the pleura upon each where the smoothness of the mem- 
brane has been impaired by disease. 

Again, many of the structural changes produced by disease, give 
rise to certain alterations in the sounds heard at the surface of the 
chest in speaking or coughing, which alterations are valuable signs 
of these particular changes. Now the morbid phenomena observed 
on the surface of the chest when the patient speaks are similar to 
some which may be observed in health, but only in particular situa- 
tions. Thus, when the stethoscope is applied over the larynx of a 
person whilst he is speaking, the sound appears to proceed along the 
instrument to the ear of the listener, much as if the mouth of the 
speaker were applied to that of the instrument. This is termed 
laryngophony. But when a similar phenomenon is observed on the 
surface of the chest (while it is not in health) it is called pectoriloquy. 
Again, when the ear of the stethoscope is placed between the scapulse, 
in many persons the voice seems not so much to proceed from the 
part upon which it rests as to traverse it ; it is, in fact, heard at that 
spot, but seems to be crossing, as if some one were speaking through 
a quill laid across the bell of the instrument or the ear of the listener. 
This is bronchophony, which is also observed as a morbid phenome- 
non on the surface of the chest. 

These sounds are audible on the surface of the chest, and become 
morbid phenomena under the following conditions: — Pectoriloquy 
occurs when there is a large hollow having each diameter as large at 
least as that of the trachea, surrounded by a substance more homo- 
geneous than healthy inflated lung, and of greater density. Bron- 
chophony, again, takes place when there is interposed between the 
surface where the ear or the stethoscope is applied, and a bronchial 
tube, a substance of greater density than healthy lung, such as con- 
solidated lung, or lung compressed by fluid, with the fluid itself. 

It would be out of place here to enter minutely into the examina- 
tion of the causes of these phenomena upon acoustic principles ; but 
as some confusion appears to have arisen from the views put forward 
some years ago by Professor Skoda, it may be well to submit the 
following brief explanation : — In the healthy condition of the lungs 
and air passages, the vibrations of the vocal chords upon which the 
voice depends, are propagated downwards along the trachea and large 
bronchi — these vibrations being communicated both to the walls of 
the trachea and large bronchi, and to the column of air contained 
within them;"* but the bronchi become divided into innumerable 
branches and twigs, which are again surrounded by the spongy lung, 

* According to the views of Dr. Skoda, this sound is produced by the occurrence of 
what is termed consonance ; but it must he obv'o is to those acquainted with the subject, 
that, for the production of this latter phenomenon, there is required a relation between 
the note or tone of the tubes and that produced at the vocal chords, which would not, 
according to all ordinary probability, be so uniformly present as it must be to produce 
the common occurrence of bronchophony. 



136 AUSCULATION". 

so that not only are the vocal vibrations broken and obstructed by 
being thus diverted, into innumerable directions, or in other words, 
their power of consonating destroyed, but they are also muffled, and, 
as it were, smothered, by the heterogeneous substance which sur- 
rounds them, which also prevents any sounds which may be excited 
in them being propagated to the surface of the chest. When, how- 
ever, instead of spongy lung and the minute ramifications of the 
bronchi, a larger tube is surrounded by a more dense or homo- 
geneous structure, its power of transmitting the sonorous vibrations 
will be increased, and if the consolidation be extensive those vibra- 
tions which are excited in the walls of the tube, as well as the air 
contained in it, will be propagated directly to the surface. Thus, 
lung consolidated by inflammation affords the most favourable con- 
dition for the phenomena, provided the consolidation extends to the 
surface of the organ. Effused fluid, again, will propagate these 
sounds better than the non-homogeneous lung, but by no means so 
powerfully as air and solids. 

The opinion of Dr. Skoda that bronchophony is wholly produced 
by a consonance between the air in the tubes and the voice, is opposed 
to the explanation which has just been given, and appears to be 
based upon some confusion between consonance and propagation of 
sound, though it is conceded that the power of consonating must be 
much increased in the tubes by their being surrounded and sup- 
ported by condensed lung. 

The diagnostic import of the various sounds observed in the aus- 
cultation of the voice, as well as their various modifications, will be 
best considered in connection with the diseases in which they occur. 

The signs observed in coughing agree both as to the principles 
upon which they may be explained, and their diagnostic significance, 
so closely with those of the voice as scarcely to require a separate 
notice in this place. 

Another mode in which sound is available for the detection of dis- 
ease is the applying the ear to the chest of the patient and giving 
him a sudden jerk; this is termed succussion, and under certain dis- 
eased conditions a splashing may be heard like that of a small cask 
partly filled with water. This sound, in fact, depends upon the 
presence of air and fluid in the same cavity. 

Of the sounds of the heart, both in health and disease, it will be 
most convenient to speak when we come to treat of the affections of 
that organ. 

We may now say a few words about the practice of auscultation. 
Auscultation, like percussion, is of two kinds, immediate and mediate. 
The former consists in the direct application of the ear of the listener 
to the chest of the patient; the latter in the use of an instrument 
termed a stethoscope, to convey the sound from the one to the other. 
Each of these methods has its advantages, for there can be no doubt 
that where the ear can be applied closely to the surface of the chest, 
it must receive the sounds which are present there more accurately 
than if they were exposed to being modified by transmission through 
some other substance. But the ear cannot well be applied to the sur- 



\ 



ASCULTATION". 137 

face of tlie cliest in all situations and under all circumstances, and 
therefore it often becomes necessary to have recourse to the sthethos- 
cope. This instrument has also the further advantage, that although 
by its assistance we can hardly hear so plainly as with the naked ear, 
we can locate the sounds more accurately. It is, however, quite in- 
dispensable that the operator should be well practised in both methods. 
There has been a difference of opinion as to the mode in which the 
sound is transmitted from the chest to the ear, some believing that it 
is conveyed by the walls of the instrument, where a hollow one is 
used; others, that it is propagated by the column of confined air 
within it. Now if the former opinion be correct — and the fact that 
the sonorous vibrations with which we have to do are those existing 
on the surface of the chest, and consequently taking place on a solid, 
would lead us to believe that it is so — a solid instrument should be 
preferred to a hollow one. Accordingly solid stethoscopes have been 
constructed, and several practitioners have believed that they heard 
better with them than with the ordinary hollow ones. Practically, 
however, there is little if any real difference, and the rules which it 
is most important to observe in the choice of a stethoscope are, that 
the ear-piece should upon trial be found well-suited to the ear of him 
who is to use it; that the base of the bell should not be too large, 
that is to say, not more than from an inch to an inch and a quarter 
in diameter, as if it be larger than this it cannot be so accurately 
applied. It is also desirable that the stethoscope should be of the 
same material throughout, or at least that there should be a con- 
tinuity of the fibres of the wood from the base to the centre of the 
ear-piece. 



138 CYNANCHE, LARYNGITIS, CROUP. 



X. 

CYNANCHE, LARYNGITIS, CROUP. 

Ix treating of the diseases of the different regions of the body, it is 
expedient to begin with those of the viscera of the trunk, since these 
may be considered as the rudimentary, being more often the cause 
of disease in other parts than the consequence of them ; and the 
reason of this is obvious, for in one or other of the great cavities of 
the trunk, reside the organs which form, elaborate, move, and purify, 
the blood. "We therefore at once proceed to inflammation of the 
lungs and air-passages. 

Of the inflammation of the organs of respiration, that which natu- 
rally presents itself to our notice is cynanche tonsillaris, or inflamma- 
tion of the tonsils. 

This disease is one, about the diagnosis of which there is no great 
difficulty, as the symptoms are apparent, and the part immediately 
affected is accessible to inspection. It has been characterized by 
Cullen as affecting the mucous membrane of the fauces, and more 
especially of the tonsils ; with swelling and redness, the accompany- 
ing fever being a synocha. The disease often commences with strong 
pains in the limbs, and general lassitude, followed by flushings of 
heat and thirst, with increased frequency and sharpness of the pulse, 
and a furred and somewhat coated tongue, and severe headache — 
with the symptoms, in short, of the commencement of inflammatory 
fever ; though it not uncommonly happens, on the other hand, that 
the local signs are the first to manifest themselves. These consist, 
in the first instance, in a feeling of soreness and constriction in the 
throat, with painful deglutition, and a difficulty in speaking, attended 
with a peculiar character of the voice, which may be readily recog- 
nized, though not very easily described ; but may, perhaps, be com- 
pared to an attempt at speaking whilst a morsel of food is in the 
fauces. The respiration is at first but little affected. Upon looking 
into the mouth, we see the membrane covering the fauces, the 
velum, the uvula, and the tonsils very red, and the latter much 
swollen. Thus far we have the redness and tension proceeding from 
the congestive stage of inflammation, with diminution of the secre- 
tion of the part, but, as the disease proceeds, one of its consequences, 
the increase of the secretion, takes place in the form of a copious and 
transparent, rather viscid frothy mucus, which, as the patient is 
unable to swallow without pain, 'produces continual annoyance from 
his efforts to expel it. 

Small opaque whitish spots now begin to show themselves ; these 
might be, by careless observers, mistaken for incipient sloughs or 
ulcers ; but are in reality effusions chiefly from the follicles — fibrin- 
ous shreds or globules, giving the appearance of films of lymph to 
the exuded mucus. There is now great difficulty in opening the 



CYNANCHE — PROGRESS. 139 

mouth, it being often impossible to separate the jaws far enough to 
admit one finger between the teeth, or sufficiently to allow the pas- 
sage of the tongue, which, independently of this, is protruded with 
much pain and difficulty, on account of the inflammation about the 
pharynx. When seen, the tongue is perceived to be covered with a 
thick creamy mucus, and streaming with the increased secretion from 
the fauces, and the pulse is thick and sharp, but rarely hard. 

The inflammation may now be said to be at its height, and may 
commonly be expected, unless any great extension to the neighbor- 
ing parts takes place, either speedily to subside, or to proceed to 
suppuration. Sometimes the inflammation extends along the mucous 
lining of the Eustachian tube, producing pain in the ear ; this pain, 
indeed, is said to indicate approaching suppuration, and certainly it 
often precedes it. The disease may be, indeed, attended with still 
more urgent symptoms, apparently more deeply seated, or involving 
to a greater extent the submucous areolar tissue ; but these more 
severe cases are generally of a specific character, as diffuse erysipela- 
tous inflammation, or that of scarlatina, constituting the cynanche 
maligna, to be described hereafter. 

If resolution of the inflammation do not take place, suppuration 
commonly ensues, in which case the fever is protracted for a few 
days longer, or even a fresh accession takes place, ushered in by 
rigors. The tonsils become more swollen and distended with pus, 
which may often be seen through the attenuated membrane. This 
abscess at length bursts, discharges a small quantity of highly offen- 
sive puriform matter, and the patient is instantly relieved. 

This disease, though very painful, and often attended with much 
distress to the patient, is, in its simple form, rarely a dangerous one ; 
it for the most part yields in the commencement to prompt treat- 
ment, by which suppuration is arrested ; and where it does take 
place, and where great obstruction to the breathing follows, this may 
almost always be instantaneously relieved by opening the abscess. 
Perhaps the only cases in which cynanche proves fatal, are those of 
a specific character already mentioned, and that spoken of as extend- 
ing down into the areolar tissue. 

There is, indeed, another form of this disease, to which the term 
dyphiherite has been applied by French authors, and which is more 
dangerous than the ordinary cynanche, and is probably of specific 
character, since it has occasionally prevailed epidemically; in this, 
small patches of flocculent lymph appear upon the surface of the 
tonsils and fauces, and extend into the pharynx, and sometimes 
down the oesophagus or into the larynx, in which latter case it may 
produce suffocation, as in croup. This form is also dangerous from 
the depressing character of the typhoid fever which attends it, threat- 
ening death from sinking. 

This disease may, however, assume a tedious and protracted form 
(1) in persons of a sluggish circulation, in whom the inflamed part 
becomes of a purplish colour, with a loose condition of the velum, 
and perhaps elongated uvula, constituting what is commonly known 
as relaxed sore throat. (2.) In those of a scrofulous habit, especially 



140 PROGNOSIS — TREATMENT. 

children, the tonsils are apt to remain swollen and indurated, and 
sometimes after repeated canses of irritation, pass into a state of 
chronic ulceration. (3.) In those whose constitutions have been 
tainted by syphilis or mercury. 

In the cases of simple cynanche, the object at the commencement 
of the inflammation should be to cut it short, or, in other words, to 
induce its resolution. For this purpose, decided and vigorous, 
though not violent, antiphlogistic measures, should be pursued. 
These should consist of evacuants, derivatives, sedatives, and the 
antiphlogistic regimen. 

It is not often that general bleeding is required in this disease ; in 
robust subjects, however, when the inflammatory symptoms threaten 
to be very severe, it may be resorted to, and must then be carried to 
such an extent as to produce a decided impression upon the system ; 
such cases are, however, rare, but when they do occur, general bleed- 
ing is to be preferred to local. Another evacuant which is often of 
signal service in the commencement of cynanche, is an emetic ; 
indeed, it very commonly happens that a full emetic, followed by 
pretty free purging, arrests the disease, and the patient becomes con- 
valescent in the course of twenty-four hours.(16)* 

When the disease is too far advanced to render it probable that it 
will be cut short by these means, but the inflammation is still in its 
active stage, as shown by the redness of the tonsils, and some degree 
of sharpness in the pulse ; diaphoretic and even nauseating medicines 
may be given, and the patient kept upon a light diet, care being also 
taken to secure a free action of the bowels.(17)f 

*(16) R Antim. pot. tart, gr. j. 

Pulv. Ipecac. ►} j. Misce. 
Ft. Pulv. ; for a dose. 

R Hydr. Chlor. gr. ij. 

Ext. Coloc. co. gr viij. Misce. 
Ft. Pil. ij. ; to be taken after an interval of three hours. 

Or the emetic and purgative may be given in combination, as in the following mix- 
ture : — 

R. Mag. Sulphat. 5 vj. 

Antim. Pot. tart. gr. iij. 
Aq. purse, § iij. 
A large spoonful to be taken every half hour until full vomiting is induced. 
The common effect of this mixture "will be, after a few doses, to excite full vomiting, 
which will generally be quickly followed by a free action of the bowels. 

f(17) R. Vin. Antim. Pot. tart. 5 ii. 
Sp. iEth. nit. gi. 
Tinct. Hyoscyami, g i. 
Mist. Acacise. 
Syrupi Aurant. aa 5 ss. 
Liq. Ammon. acet. J jss. 
Mist. Camphora?, q s. 
To make a^ vi. mixture, of which the fourth part is to be taken every fourth hour. 

]J. Pulv. Ipecac, co. gr. iv. 

Ext. Coloc. co. gr. vj. Misce. 
Ft. Pil. ij. ; to be taken at bed-time. 



CTNANCHE — TREATMENT, 141 

"Where the bowels are irritable, which, however, is not generally 
the case, the wine of ipecacuanha may be substituted for that of the 
antimony ; or the same may be done when the pulse is so compres- 
sible as to justify the apprehension that the latter medicine may be 
too depressing ; still, as a general rule, cynanche is a disease to which 
in its earlier stages antimony is especially applicable. At the com- 
mencement of cynanche, astringent gargles aggravate rather than 
relieve the suffering of the patient, but the gargling with warm 
barley water is often productive of much comfort, and probably 
relieves the tension of the vessels by favouring the secretion from 
the part. The inhalation of the steam of warm water is, perhaps, 
still better, as it is unattended with the action of the muscles of 
deglutition requisite for gargling. 

When the inflammation has not been treated with sufficient activity, 
or when, as it sometimes will do, it proceeds in defiance of the most 
prompt measures, a change of treatment will generally be advisable ; 
all depressing remedies should be laid aside, and moderate support 
given to the patient ; and if the pulse have become feeble, and there 
is much prostration (owing partly to the abstinence from food, which 
the difficulty in swallowing often compels), stimulants, as wine, will 
relieve the depression, and forward the progress of the abscess. If 
the abscess do not speedily empty itself, or the accumulation of 
matter opposes great impediment to deglutition and respiration, it 
will become necessary to give vent to the pus, which generally affords 
instant relief to the patient. After this has been done, tonics, and 
even stimulants, may be employed, in the form of bark or quinia, 
animal diet, and a moderate allowance of wine. 

When the inflammation has not proceeded to suppuration, but has 
yielded to the remedies employed at once, there frequently remains 
a considerable degree of depression, which will be best relieved by 
moderate doses of quinia, care being taken to secure a regular action 
of the bowels ; for this purpose the disulphate of quinia, with a little 
sulphate of magnesia, in a bitter infusion acidulated with sulphuric 
acid, will be the most eligible; (18)* at the same time an astringent 
gargle (19)f may be used with benefit, as the tonsils and uvula often con- 
tinue enlarged and of a purplish colour, constituting the relaxed sore 
throat already alluded to. This latter affection, however, often comes 
on without being preceded by a decided attack of acute cynanche ; but 
in such cases the treatment should be the same as in the chronic 

* (18-) R- Quinioe Disulph. gr. vj. 
Mag;. Sulphat. g iij. 
Acid Sulphat. dil. 3 ss. 
Syrup. Aurant. Sj ss. 
Infus. Aurant. co. 5 iijss. Misce. 
Of this mixture one-fourth part is to be taken three times a day. 

f (19.) R. Aluminis, g ss. 

Mellis Rosse, ^ ss. 
Tinct. Myrrhse, 5 ss. 
Decoct. Cinchon. 5 vii. Misce. 
For a gargle. 



142 ACUTE LARYNGITIS — SYMPTOMS. 

form which lias followed tlie acute disease, though, the gargle may be 
rendered more stimulating by the addition of about half a drachm of 
tincture of capsicum ; or one of a solution of nitrate of silver may be 
used instead. A pure air and moderate exercise, with nutritious 
diet, will do much to aid the cure ; but not less important than all, 
is the negative precaution of avoiding those circumstances which are 
liable to excite a fresh attack, to which the patient will commonly 
continue for some time liable ; amongst the most active of these may 
be reckoned exposure to an atmosphere which is at once cold and 
damp ; the going from a warm and crowded place, whether church, 
theatre, ball-room, public meeting, or private party, into a cold air ; 
and the perhaps no less dangerous transition from a cold, frosty air, 
to the front of a blazing fire. 



LAKYNGITIS. 

Nearly allied to cynanche tonsillaris, but of a far more formidable 
character, is the cynanche laryngea, or laryngitis : indeed, it is to its 
tendency to run into this disease, that the first-named malady owes 
its principal, if not its only, danger. Laryngitis is, as its name im- 
ports, an inflammation of the larynx, especially of the cartilages, and 
affords an instance of inflammation excitinsr danger not so much from 
the constitutional disturbance, or the exhaustion consequent upon it, 
as by its arresting the function of a part essential to life. 

This formidable disease is mostly sudden in its invasion and rapid 
in its progress. The first complaint made by the patient is of a sore 
throat, but this is generally attended with an unusual degree of 
anxiety, and upon looking into the throat we may perceive an in- 
creased redness of the fauces, but not inflammation sufficient to 
account for the general distress. The next symptom is difficulty of 
deglutition, and when this supervenes upon those mentioned above 
it ought always to excite alarm ; at the same time the voice becomes 
husky or croaking, or perhaps more often it degenerates into a 
whisper ; there is also great dyspnoea, the respiration becoming almost 
of a crowing character, and there is a harsh, discordant, half-metallic- 
sounding cough, but for neither of these symptoms can any adequate 
cause be discovered upon exploration of the chest by auscultation. 
The patient also complains of a most painful sense of constriction, 
which he refers to the situation of the pomum Adami, and of tender- 
ness about the situation of the point of the os hyoides. About this 
period of the disease there takes place an abundant glairy secretion 
of rather stringy mucus ; and if its progress be not now arrested it 
runs speedily on to a fatal termination. The distress of the patient 
becomes greater and greater, and there is increased difficulty in 
speaking and dread of making the attempt either to speak or to 
swallow. The efforts in respiration are truly distressing, especially 
during inspiration, each attempt at which is attended by a hissing 
and sometimes almost crowing sound ; the only words uttered are 
expressive of a desire for air and a sense of suffocation, the shoulders 



PATHOLOGY — DIAGNOSIS. 143 

and clavicles are draTrn up, the neck straightened, the head being 
thrown somewhat backwards, and the accessory muscles of respira- 
tion thrown into violent action, by which the cartilages of the larynx 
are drawn down towards the sternum; the dyspnoea is liable to 
paroxysms of intense aggravation, during which the patient is nearly 
suffocated ; after a time the countenance becomes dusky, the skin 
moist and clammy, the pulse very feeble at the wrist, the impulse of 
the heart remains considerable, and the patient dies of apnoea. 

The pathology of this disease is exceedingly simple, and the symp- 
toms during life are pretty clearly explained by the morbid changes 
displayed by inspection after death. The seat of the inflammation 
is, as has been already stated, the mucous covering of the larynx and 
its cartilages, including the rima-glottidis, the epiglottis, and some- 
times the sacculi laryngis. The first effect of inflammation of the 
mucous membrane is engorgement of the minute vessels by which it 
is abundantly supplied, attended with increased nervous sensibility ; 
the consequences of this are the pain, swelling, heat, and redness of 
the part affected, and there is also in this stage of the inflammation 
diminution of the secretions of the membrane. Hence the redness 
observed in the fauces at the commencement of the disease ; the pain 
and tenderness, with difficult deglutition — the "sore throat," — the 
hoarseness of the voice, and the pain on speaking. The next stage 
in the process of mucous inflammation is that in which the inflam- 
matory products are effused, and accordingly there ensues an effusion 
of serum or liquor sanguinis into the areolar tissue underneath the 
mucous membrane, which effusion sometimes becomes of a puriform 
character ; at the same time there is often an increase in the secretion 
of the surface. Now the danger of this effusion in the part indicated 
must be apparent, and it will satisfactorily account for the distressing 
symptoms which have been described : it, of course, greatly adds to 
the SAvelling, and not only is the larynx much encroached upon and 
its canal narrowed, but the little crevice in the glottis by which the 
air passes into it is rendered less and less, and sometimes entirely 
closed by the continual swelling of the membrane and its subjacent 
areolar tissue. 

The morbid change which essentially belongs to this disease, and 
which is constantly found upon inspection after death, is infiltration 
of the areolar tissue in the part just pointed out; the mucous mem- 
brane is also reddened, thickened, and occasionally smeared with a 
puriform mucus ; it is also sometimes ulcerated ; the epiglottis is 
thickened and often erect. There are, commonly, venous congestion 
throughout the body — extensive engorgement of the lungs, and com- 
monly of the right side of the heart — signs characteristic of the mode in 
which this disease proves fatal, by apnoea. The diagnosis of laryngitis 
is fortunately not very difficult, as it is of the greatest consequence 
that the disease should be early recognized in order that it may be 
promptly treated. The loss of voice, and spasmodic breathing of 
hysterical females may be distinguished from it, by the ordinary 
signs of hysteria, and by the absence of the signs of inflammation. 
A common sore throat or hoarseness may indeed be mistaken tor this 



144 ACUTE LARYNGITIS. 

disease, or what would be worse, the latter may be regarded as a case 
only of the former. Now, although the common sore throat, which 
is a disease of no danger, does no doubt depend upon inflammation 
of the mucous membrane of the larynx, it is unattended by either 
the inflammatory fever, the general restlessness and anxiety, and the 
early occurrence of spasmodic breathing, which characterize laryn- 
gitis. Where the two former of these occur in sore throat the case 
should be carefully watched, and the first appearance of the latter 
ought to excite great alarm. From cynanche trachealis, or croup, 
laryngitis may be distinguished partly by its affecting generally 
adults, whereas the former disease is almost exclusively one of in- 
fancy or childhood ; and partly from there being no difficulty of 
swallowing in croup ; in cynanche pharyngea, on the other hand, 
there is difficulty of swallowing as well as of respiration. Tumours, 
again, whether produced by abscess, aneurism, swollen glands, or 
other morbid growth or enlargement, may by pressing either upon 
the larynx or trachea, or upon the nerves by which those parts are 
supplied (as when the recurrent nerve is pressed upon by an aneurism 
of the arch of the aorta), give rise to symptoms resembling those of 
laryngitis, and hence have been mistaken for it. The possibility of 
the existence of any of these should always be borne in mind ; and a 
careful examination of the throat and of the condition of the heart 
and large arteries as far as the state of the patient will allow, should 
always be instituted. 

The causes of acute laryngitis are exposure to cold or damp, or to 
both together; it may also be excited by mechanical or chemical 
irritation of the larynx or glottis ; and a not unfrequent cause amongst 
children is the inflammation set up about that part by the swallowing 
of scalding water. It may also be induced, as has been already 
noticed, from the extension of the inflammation of cynanche tonsil- 
laris to the larynx, or arise in the course or at the termination of 
scarlatina, measles, . small-pox, erysipelas, and sometimes of rheu- 
matism. 

The prognosis is generally unfavorable in acute laryngitis, the 
disease proving fatal in a great number of instances. We must not, 
indeed, despair under favourable circumstances, and in good con- 
stitutions, of saving our patient, notwithstanding the severity of the 
disease ; especially when remedies can be promptly applied at its 
commencement ; but if much time has been lost, and the patient is 
of a feeble constitution, apparently of a cachectic habit, or the sub- 
ject of visceral disease, — circumstances which favour the effusion of 
serum into the areolar tissue, the probability of recovery is exceed- 
ingly small. 

It must have been inferred, from what has been already said, that 
the treatment of acute laryngitis should be prompt and decisive. 
The disease is an acute inflammation, and therefore calling for anti- 
phlogistic measures, which from its dangerous position, it is most 
desirable to subdue, if possible, before it reaches that stage in which 
the truly inflammatory effusions take place ; since it is from these 
that the chief danger arises. It is, however, an inflammation of a 



TREATMENT. 145 

mucous membrane, and consequently one less directly amenable to 
the effect of blood-letting than those of some of the other tissues ; it 
is, on the other hand, to be remembered, that blood-letting, when 
applied at too late a period, or when there exists an anaemic, or rather 
spansemic state of the system, favours the effusion of serum, by ren- 
dering the blood still poorer, and thus inducing the form of the 
disease to be presently noticed under the term of oedema glottidis. 

When, therefore, the patient is of temperate habits, apparently of 
good constitution, with no tendency to leucophlegmasia or anaemia, 
and the pulse is firm as well as sharp, and the tongue white, bleed- 
ing in a full stream, until some decided impression has been produced 
upon the heart, and repeated in a few hours if the pulse and the 
general condition of the patient are such as to justify it, has often 
appeared to cut short the inflammation : and there can be no doubt, 
that under such circumstances, it is the most efficient remedy at our 
disposal ; but on the other hand, it more frequently happens that the 
persons in whom this disease occurs, are of previously unsound con- 
stitution, or weakened by previous disease, as when the laryngitis 
supervenes upon measles, scarlatina, or erysipelas, and in whom the 
use of the lancet would consequently be dangerous ; or if this be not the 
case, the disease may be so far advanced as to have greatly depressed 
the system by the obstructed respiration, and consequent circulation 
of carbonized blood : or if it have already existed some hours, or has 
been fully established, experience teaches that blood-letting is nearly 
inefficacious. It has been recommended by some authors to apply 
leeches to the throat, more or less, according to the state of the sys- 
tem or activity of the disease, in those cases, where, for the reasons 
assigned above, it might not be considered safe to bleed from the arm ; 
or where, bleeding having been already performed, it might not be 
justifiable to repeat it ; but there is one great objection to the use of 
leeches in this situation, namely, that it is apt to be followed by the 
effusion of serum into the subjacent cellular tissue, the occurrence of 
which, in that situation, is one of the dangers to be apprehended in 
this disease. Cupping at the back of the neck, as recommended by 
Dr. Watson, is certainly a preferable expedient. 

Although blood-letting, whether general or topical, is not to be 
neglected in this disease, when it can be performed with safety, we 
are not to overlook other remedies which we possess as efficacious, 
and perhaps less dangerous. Amongst these, as applicable at the 
very early stages of the disease, must be mentioned an efficient 
emetic ; indeed, a moderately -full dose of antimony and ipecacuanha 
in the form already recommended (p. 140) will sometimes arrest at 
the outset attacks of a very threatening character. Our attention 
should next be turned to fulfilling those indications presented by the 
nature and symptoms of the disease, and these are to reduce the 
action of the heart and large vessels, to reduce, too, the increased 
action of the capillaries of the part and determination of blood to 
them, and to allay the excessive nervous excitement of the part. 
These three indications are admirably fulfilled by the combination of 
antimony, calomel, and opium, already recommended in speaking of 

10 



146 ACUTE LARYNGITIS. 

the treatment of inflammation. It should be observed, however, that 
as it is in the highest degree desirable to make an early impression 
upon the heart, and to maintain it, the antimony may be given in 
somewhat larger doses than there recommended, whereas the ten- 
dency of calomel to set up inflammation about the fauces, and to 
induce ulceration of the larynx itself, suggests the prudence of a more 
limited use of that remedy ; for the opium again there is a special 
indication in the restlessness and anxiety of the patient, as well as 
the frequent paroxysms of spasmodic constriction of the larynx, and 
it may accordingly be more freely used, provided there be not much 
lividity arising from the impeded aeration of the blood, as it ought 
always to be remembered in this, as well as in several other diseases, 
that where this is the case, there is a diminished tolerance of opium. 
The best plan generally will be to give every three hours a pill com- 
posed according to (F. 3, p. 103); in the interval to administer a 
draught, containing from half a drachm to a drachm of antimonial 
wine, with or without a few drops of tincture of opium, and the addi- 
tion, if necessary, of a little sulphate of magnesia : the antimony in 
the pills, or in the draughts, should also be gradually increased, until 
it produce a decided tendency to nausea. The early application of 
blisters, which is objectionable in all inflammatory diseases, is in this 
case especially so, from the danger of producing infiltration of serum 
into the subjacent areolar tissue ; indeed it is more than doubtful if 
they ought to be applied to the throat at any period of acute laryn- 
gitis, though when the more active symptoms have subsided, a blister 
may be put upon the back of the neck. Flannel well wrung out in 
water so hot as almost to produce vesication, and applied to the 
throat when the paroxysms of dyspnoea are most urgent, often affords 
very marked relief. In the treatment of acute laryngitis, it is indis- 
pensable that the temperature of the apartment should be kept uni- 
formly at a moderately high standard ; 65° of Fahrenheit is about 
the best, and from this it should never, if possible, deviate by more 
than one or two degrees ; and perhaps it ought never to fall below 
it. By a steady perseverance in these means we may often succeed 
in carrying the patient safely through this most dangerous disease, 
which not uncommonly recedes just as the signs of the action of 
mercury upon the system are beginning to show themselves ; but it 
must be admitted that the chances of doing so, where the inflamma- 
tion has been fully established, are less than the chances against us ; 
and when the disease is in its latter stages but little can be effected 
by medicine. Under these circumstances, it has been proposed, and 
the operation has sometimes succeeded, to perform tracheotomy. But 
though the operation has succeeded, it has often failed, the inflamma- 
tion extending down the trachea ; still the question as to its expedi- 
ency in any particular instance is not to be lost sight of. 

In simple acute laryngitis, the disease is situated, as already de- 
scribed, in the neighbourhood of the glottis and chordse vocales; 
and, consequently, when it is threatening to be fatal by suffocation, 
it is here that the obstruction to the admission of air to the lungs 
takes place, and therefore if an opening be made below it in the 



CHRONIC LARYNGITIS. 147 

trachea, air may pass into the lungs, and thus, the immediate cause 
of death being obviated, time is gained for combating the primary 
disease. It is, however, necessary to ascertain that the obstruction is 
limited to the above situation, and therefore, before deciding upon 
the operation, the greatest care must be used to ascertain that the 
disease is not simulated by any of those which have been mentioned 
as liable to be confounded with it, and also that it is not complicated 
with inflammation of the trachea, in which case the operation would 
be productive rather of harm than benefit; or with such mischief in 
the lungs as would render it useless. It may, however, be stated in 
recapitulation, that when the disease, upon most cautious examina- 
tion, is found to be really laryngitis, and further that it is solely 
laryngitis, so far as to be free from any complication which would 
either add to the danger of tracheotomy, or render the operation 
futile, and if it seems to gain ground in defiance of the steady use of 
the means which have been recommended, the operation may be per- 
formed with a justifying chance of success. 

Sound discretion is also required in deciding when it is to be per- 
formed, for intractable as this disease often is, it is not so certainly 
so as to justify so formidable an operation before the trial of every 
treatment, but if it have resisted such treatment, and shows no sign 
of subsidence after about forty-eight hours, the operation may be 
performed without waiting for the signs of impending suffocation ; 
but should such signs appear before then, of course it ought to be 
done without delay ; and it may be added, that under such, the 
operation ought not to be abandoned because it appears too late, 
since cases have occurred, both of what may be termed spontaneous 
laryngitis, and also of those supervening upon swallowing hot water, 
or other local irritation, in which the pulse had ceased at the wrist, 
and the countenance become perfectly livid, where the pulse hag 
returned, and the lividity vanished, when air was admitted through 
the opening made by the surgeon in the trachea. 

The inflammation of the larynx, which is excited by the attempt 
to swallow boiling water, not an uncommon occurrence amongst 
children, as it is intense, and apt to prove fatal very speedily, is a 
case in which tracheotomy is generally expedient ; as it often is also 
in that form of the disease which occurs in the course of erysipelas, 
and other eruptive fevers, where the active antiphlogistic measures 
required to subdue the inflammation cannot be tolerated in the 
weakened state of the system. 

(Edema of the glottis, which is to be distinguished from acute 
laryngitis, by the absence of the signs of active inflammation, and is 
characterized by a loud hissing respiration, happens, and that not 
very rarely, as a secondary consequence of other and sometimes 
remote affections. Thus it may take place from tumors pressing 
upon the large veins in the neck, as in aneurism of the thoracic 
aorta ; and again in dropsy, arising from disease of the kidneys, it 
sometimes occurs very suddenly, and is one of the recognized modes 
in which that disease proves fatal. In such cases also we can have 



14:8 PROGNOSIS — TREATMENT. 

little hope from any other measure than tracheotomy, though this of 
course can only save life for a time. 

The larynx is also liable to chronic inflammation, which renders 
the membrane injected, thickened, corrugated, and ultimately ulcer- 
ated ; the perichondrium of the cartilages becoming also implicated, 
and leading to necrosis of the cartilages themselves. The same thing 
also happens to the epiglottis, which is occasionally partly destroyed, 
and thus rendered inadequate to the closure of the rima. The lining 
membrane of the sacculi laryngis also becomes inflamed and ulcer- 
ated. This chronic form of the disease, which is more certainly, 
though less speedily fatal, than the acute, sometimes supervenes upon 
it. It also arises from syphilis, from the abuse of mercury, and 
sometimes from a common sore throat induced by the ordinary 
causes, occurring in a patient whose constitution has been much im- 
paired by the above or other causes. The chief symptoms are first 
of all hoarseness, subsequently loss of voice (the patient speaking in 
a whisper), owing to the injury of the parts about the larynx, wherein 
the voice, as distinguished from a whisper, is formed. There is also 
a ringing cough, with generally a copious puriform expectoration, 
and considerable emaciation ; this frequently continues to increase, 
hectic supervenes, and the patient dies with all the symptoms of 
phthisis pulmonalis, constituting what in fact is frequently spoken of 
as phthisis laryngea. 

This last form of the disease, however, is rarely an uncomplicated 
or even primary one ; the primary affection being generally in the 
lungs, and the laryngeal one is little more than a complication, or 
rather consequence, though often a very distressing one, of disease 
in those organs. TV nen the chronic laryngitis, as a primary affection, 
proceeds to a fatal termination, there is increasing dyspnoea, total loss 
of laryngeal sounds, and ultimately of the power of articulation even 
in a whisper, difficulty of swallowing, the attempt at which often 
threatens to induce suffocation, owing to the continually open state 
of the glottis, and the patient dies, either suffocated from the closure 
of the rima or of the larynx, by the thickened membrane, or exhausted 
by the protracted ulceration and the difficulty of swallowing. 

The only morbid appearances necessarily present in such cases, are 
the thickening and ulceration of the lining membrane of the larynx, 
and the ossification and necrosis of the cartilages already described. 

The prognosis in this disease is, as has been already stated, unfa- 
vourable; when indeed it is merely a consequence of the acute 
disease, there is a reasonable hope of effecting a cure. When, how- 
ever, it occurs in a previously broken constitution, especially one 
which has been impaired by syphilis or mercury, or, which is equally 
common, by both combined, and ulceration of the cartilages has taken 
place, little can be hoped for beyond palliation ; and in those cases 
which are merely complications of phthisis, the prospect is altogether 
desperate. 

The treatment as well as the prognosis of chronic laryngitis must 
be guided mainly by the nature of the exciting cause ; in those cases 
which are the consequence of the acute disease, gentle antiphlogistic 



CHKONIC LARYNGITIS. 1-19 

measures will still, no doubt, be occasionally required, but these 
must, both in kind and in degree, be such as are not likely to lower 
the strength of the patient. A few leeches may sometimes be applied 
to the throat, and blistering is not so objectionable here as in the 
acute disease, but it is far better to apply it to the back of the neck. 
Hot fomentations, however, and poultices are generally to be pre- 
ferred as external applications, unless there be signs of fresh excite- 
ment indicating a return of acute or sub-acute inflammation. A mild 
mercurial alterative (20*) will be of service for a short time, provided 
its action be carefully watched, and it be withdrawn as soon as the 
least effect is produced upon the gums. A soothing anodyne mix- 
ture (2 If) should also be employed at the same time. 

A useful remedy in the treatment of chronic laryngitis, is the 
application of a strong solution of nitrate of silver to the glottis, in 
the mode which has not inaptly been termed swabbing by Mr. Vance, 
who introduced it.J This is performed by passing a piece of sponge 
saturated with a strong solution of nitrate of silver down the throat, 
(if no violent spasmodic action be excited), and pressing it against 
the upper surface of the larynx. 

In what may be termed the cachectic form of chronic laryngitis, 
our chief reliance must be placed upon restoring the strength of the 
constitution ; and perhaps the best means for this end will be country 
air, or the sea-side, in a tolerably sheltered situation ; and the bene- 
ficial effect of these may be aided by the iodide of potassium, with 
sarsaparilla or cinchona, or mineral acids with one of the latter : the 
action of the skin also, which is of great importance, may be improved 
by an occasional warm bath. 

When there is increasing dyspnoea, and threatened suffocation 
from the thickening of the lining membrane, the operation of trache- 
otomy affords the only prospect of prolonging life, though but for a 
short time. Still, the present relief, and addition of a few days, or it 
may be a few weeks, or even months, to life are not to be disregarded. 

* (20) R. Pil. Hydr. Chlor. co. gr. iv. 
Pulv. Ipecac, gr. v. 
Ft. Pil. ; to be taken at bed time 

f (21) R. Pot. Nitrat-9 ij. 
Tinct. Camph. co. 5 ss. 
Oxymel simplicis, 3 iiss. 
Aq. purge, ^ iij. Misce. 
A large spoonful to be taken four times a day. 

% Watson's Lectures. The strength of the solution may be five grains to a drachm. 



150 CEOUP — PREMONITORY SYMPTOMS. 



CEOUP. 

Nearly related to laryngitis, is the croup, cynanche trachealis, or 
tracheitis. This disease is to children much what the former is to 
adults, though it differs from it in many important respects. Like 
laryngitis, it is sudden in its attacks, and often speedily fatal ; like it, 
too, it produces death by opposing the passage of the air to the bron- 
chi, but it differs from it in producing this obstruction not by swelling 
of the lining membrane, but by the effusion of a plastic deposit upon 
it; it also differs in its seat, as it occurs in the trachea, and, which 
renders it doubly formidable, it is very apt to extend down into the 
bronchi. It is, too, a disease of children, occurring almost exclu- 
sively between the periods of weaning and puberty, whereas laryn- 
gitis, though it may occasionally happen to children, is almost entirely 
a disease of adults. 

The croup consists essentially in intense inflammation of the mucous 
lining of the trachea, leading, if unchecked, to the effusion of a layer 
of solid albuminous matter, which obstructs the trachea, and causes 
death by suffocation. 

The course of the disease has been variously divided by authors 
into steps or stages. It is, however, important for practical purposes 
to recognise three only, viz., the premonitory stage, the stage of con- 
firmed inflammation, and the stage of impending suffocation. 

The premonitory stage, though generally present, may sometimes 
be so slightly marked as to escape observation; or at others it is 
very transient, being only of a few hours' duration, but in most cases 
it occupies a period of nearly two days. The child is commonly 
attacked with the ordinary symptoms of common catarrh, with per- 
haps a greater degree of febrile disturbance than attends the latter 
disease ; thus we have chills, followed by heat of skin, lassitude, loss 
of appetite, a rather flushed countenance, and increased hardness of 
pulse, with headache, sneezing, coryza; and, in addition to these, a 
short cough and a hoarseness, which, even at this period of the dis- 
ease, gives to the voice a peculiarly harsh and metallic character. 
This latter symptom is, however, often wanting, and as to the rest, 
they at times present no distinctive characters by which the croup 
can at this period be distinguished from a common catarrh. In very 
young children the only premonitory symptoms may be restlessness, 
flushing of heat on the surface, a short, frequent cough, sleeplessness 
at night, and uneasiness about the throat, manifested by the frequent 
application of the hand to the part. 

We have seen that there are no very decided signs, certainly no 
distinctly diagnostic ones, by which the premonitory stage of croup 
may be recognised; at the same time, we may generally be enabled, 
by the aggregate of the symptoms, to suspect its approach, and take 
measures for its prevention ; and it may be well to bear in mind that 
in young children catarrh seldom causes hoarseness, and therefore, 
that where the latter is superadded to catarrhal symptoms, in the 



SYMPTOMS. 151 

absence of any difficulty of swallowing, or distinct tumefaction about 
the throat, we should never omit to warn the parents or friends of 
what may be apprehended, and this the more, if it occur in a child 
who has evinced a tendency to the disease, or even in a family, or a 
district, in which it is prevalent. 

It generally happens, however, that medical aid is not obtained 
until the disease is nearly fully developed ; when we have hoarseness, 
if it have not been present before ; or the previously existing hoarse- 
ness has assumed a peculiar thrill, or cracked sound, or the voice dis- 
appears altogether ; this last, however, would indicate that the disease 
has extended to the larynx. The characteristic cough of croup now 
begins to be heard; this cough is perhaps most aptly described by 
the expression "tussis clangosa" of Cullen; it has been compared to 
the barking of a puppy, or coughing through a brass tube ; it is not, 
however, very readily described, though it may be easily recognised 
by any one who has heard it. The inspirations following the cough 
are slow and hissing, or accompanied by a crowing sound. The 
respiration between the fits of coughing is much obstructed, and each 
inspiration is attended with the hissing or crowing sound just 
noticed ; the expiration is quick, but less difficult than the inspira- 
tion ; the head is thrown back, and, at each act of inspiration, the 
pomum Adami is forcibly drawn down towards the sternum; the 
countenance is congested and turgid, and sometimes bedewed with 
perspiration; the skin is hot, the pulse sharp, and the tongue white; 
there is little or no expectoration. The bowels are constipated, and 
the urine scanty. The above symptoms generally come on towards 
evening : often when the patient has been affected during the previous 
day with the signs of the premonitory stage, he is attacked by them 
in the night on waking from sleep ; they often subside towards morn- 
ing, and the remission continues through the day, but towards 
evening, or again upon awaking from sleep, they return with greater 
severity than ever; the dyspnoea is aggravated, and the croupy cough 
and breathing more marked ; — the countenance congested, the cheeks 
more livid, and the eyes more turgid — the pulse, which continues 
sharp, becomes very frequent, small, and contracted; — the voice 
becomes feebler, and more whispering; — the cough, up to this time 
dry, or attended with scanty mucous or sanguineous expectoration, 
becomes husky, with frequent efforts to expel what is felt to be in 
the trachea; if, however, vomiting follow, and especially if it give 
rise to the excretion of albuminous or membranous matter, a con- 
siderable relief is often obtained; this relief may, indeed, be only 
momentary, but sometimes it is the commencement of a gradual sub- 
sidence of all the symptoms. The signs afforded by auscultation are, 
a louder sound over the trachea; diminished respiratory murmur 
over the chest, but good resonance on percussion. When, however, 
the disease has extended down the bronchi, there is, in addition to 
the above, bronchial or tubular respiration. 

The above symptoms are rarely continued, but present remissions, 
as above stated; if, however, the disease do not subside, or is 
unchecked by remedies, these remissions become less and less ; and 



152 ceo up. 

their disappearing altogether may be said to characterize the stage of 
impending suffocation, which is also marked by increased frequency 
and difficulty of respiration, and failure of the moving powers of the 
circulation — the voice and articulation becoming nearly lost, the 
laborious action of the muscles of respiration, and expansion of the 
alse nasi more marked, and the pulse feeble, irregular, and even inter- 
mittent. The eyes are now sunk and glassy ; the head thrown back; 
the countenance dusky; the skin cold, and bedewed with a clammy 
perspiration ; the tongue loaded and congested ; the tips of the fingers 
livid ; the veins deeply marked, and those about the neck distended. 
It may happen that, even in this apparently hopeless stage of the 
disease, a copious expectoration takes place, in which some mem- 
branous matter is excreted, and the breathing is relieved, and the 
other urgent symptoms subside; it more commonly happens, how- 
ever, either that the child sinks exhausted, or is suffocated in a 
violent paroxysm of dyspnoea ; or it may be that he is carried off by 
convulsions arising from the congestion of the brain. 

The most remarkable, and indeed the essential morbid appear- 
ance upon dissection after death, is an albuminous or nbro-albuminous 
layer, which occurs either in separate patches, or, in the best marked 
cases, as an uniform membrane lining the whole of the trachea, and 
sometimes extending far down the bronchial tubes : this membranous 
layer must not, however, be confounded with the layers of plastic 
lymph, which occur upon the surfaces of inflamed serous membranes, 
since it is incapable of organization, and may be readily detached 
from the surface on which it is poured out. 

Such are the symptoms and progress of the disease, in what may 
be termed its most acute and perfect form; in such cases the patho- 
logy may be readily understood. Croup in this form is, as was 
stated at the commencement, essentially an intense inflammation of 
the trachea. This inflammation, like others, is at the commencement 
attended with congestion and consequent turgescence of the part, and 
diminution of its secretions; during this condition we have the 
beginning of the dyspnoea, the harsh, husky voice, and dry cough; 
or the larynx is often more or less involved in the inflammation, and 
when this is not the case, it is apt to be spasmodically affected by the 
irritation existing in the trachea. This congestion may be for a time 
relieved by the occasional increase in the secretion of the part; and 
with it the dyspnoea will be relieved also; as the disease proceeds, 
however, the peculiar effusion of the inflammation begins to show 
itself; this, in the present instance, where the inflammation is intense, 
and involving the submucous areolar tissue, contains a considerable 
portion of fibrine, which gives it a filamentous or membranous 
appearance, and this prevails to so great an extent as to line the 
trachea with a continuous layer. Now the effect of the presence of 
this membranous matter in the trachea, must be much the same as 
that of a foreign body (which indeed it is) in the same situation; and 
hence the frequent paroxysmal and suffocating efforts to clear the 
tube of what is felt to be lodged there ; these efforts being always 
attended by spasmodic contractions of the muscles of the larynx. 



VARIETIES. 153 

The effects of this mechanical obstruction of the trachea, and frequent 
spasmodic closure of the glottis, are too obvious to require to be 
minutely detailed. They may be summed up as, imperfect aeration 
of the blood, and engorgement of the lungs, of the right side of the 
heart, of the portal system, and of those organs which return their 
blood by the ascending cava, — hence the lividity, the dark stools, 
and scanty urine — also venous engorgement of those parts which 
return their blood by the descending cava — hence the livid counte- 
nance, the venous congestion of the brain, particularly at the base 
and medulla oblongata, and occasional occurrence of convulsions 
towards the close of the disease, — death by apnoea. 

As the true croup sometimes makes its attack very suddenly, and 
gives rise to membranous effusion very quickly, it may prove fatal in 
the course of twenty -four hours ; the most common time, however, 
for a fatal termination, is on the fourth day. It varies also in other 
cases from two or three to eight or even nine days, the inflammation 
not subsiding immediately after the expulsion of the membranous 
effusion ; sometimes, too, it exists in a less active state, and, according 
to some authors, gives rise to ulceration; from this chronic form the 
patient may recover by judicious management, though he often sinks 
after a period of some weeks. 

In the explanation of the various modifications of croup, it is 
necessary to keep in mind the nervous sympathy which exists 
between the trachea and the larynx, the exquisite sensibility of these 
parts, and also the abundant supply of nervous influence to the 
larynx, and its consequent liability to spasmodic excitement. This 
spasm may be excited not only when the larynx itself is the seat of 
inflammation or irritation, but when those parts with which it is 
connected by the reflex nervous action, are so affected; and also 
when any cause of irritation exists, either at the extremities, or along 
the course, of the incident or reflected nerves, or at the convergence of 
both in the nervous centre. These facts, duly considered, may do 
much towards removing the confusion that has arisen between the 
acute and severe croup of which we have just been treating, and 
other diseases which, in respect at least to some of the most obvious 
symptoms, are very nearly allied to it. 

In the disease which has just been described, there exists a double 
cause of spasmodic action of the parts about the larynx, — 1st, the in- 
flammation in the trachea ; and, 2ndly, the membranous effusion which 
is the product of that inflammation, which acts as a foreign body, both 
opposing the access of air to the lungs and exciting efforts for its 
own dislodgment, which efforts are attended by strong spasm of the 
muscles about the larynx, and are from that circumstance often inef- 
fectual. We should, however, expect a priori that there would some- 
times occur inflammation of the lining membrane of the trachea, not 
proceeding to the membranous effusion, but exciting considerable 
spasm about the glottis and neighbouring parts, resembling what 
occurs in the earlier stages of croup ; and also, that there would occur 
such spasm, arising from some cause of irritation — other than inflam- 
mation at the extremities either of the incident or reflected nerves — 



154 croup. 

existing elsewhere along the course of those nerves, or in the nervous 
centre from which thej proceed. 

Accordingly, we do meet with a form of disease in which there are 
the inflammation of the trachea and the spasm, but without the mem- 
branous effusion; this is the mucous [or catarrhal] croup of some 
authors, though others have confounded it with the true spasmodic 
croup, " laryngismus stridulus," or child-crowing of Dr. Grooch, which 
is essentially a non-inflammatory disease, being the result, in its purest 
form, not of disease of the larynx or trachea, but of irritation either 
in the brain or medulla oblongata, or along the course of the nerves 
supplying the former parts. 

The mucous croup commonly affects very young children, that is, 
those who have been lately weaned, and is most frequently observed 
in those of apparently a leucophlegmatic temperament; its attack is 
rapid and severe, but not so sudden and violent as is that of the true 
croup ; it is preceded by coryza and other symptoms of catarrh, but 
with little fever, and generally comes on in the evening, or in the 
night, with the invasion of a shrill, ringing cough, and sibilant and 
very hurried respiration ; there does not appear to be much redness 
of the fauces, and the inflammation does not at the commencement 
extend down the bronchial tubes ; these attacks generally recur on 
the following evening or night, but after the first or second day the 
cough is attended by a mucous rattle, and the fits terminate more 
speedily in the expectoration of a glairy mucus. The disease gene- 
rally terminates in bronchitis. This form has been by some authors 
regarded as a bastard or spurious croup, but it is with much more 
justice considered as a milder form of inflammation by Dr. Copland 
and others. It is, in truth, an inflammation of the trachea, occurring 
in children in whom the nervous system is highly irritable, which cir- 
cumstance, combined with the natural irritability of the parts affected, 
accounts for the disproportionate excess of nervous excitement. 

In the true spasmodic croup, or child-crowing, we have no inflam- 
mation, and the spasm is to be explained upon the principle of con- 
vulsive action of a particular part, being frequently excited, not only 
by irritation — at the extremities of the nerves supplying that part — ■ 
of which inflammation of the part itself is one instance — or in the 
course or at the origin of those nerves, as in the cases of morbid 
growths on the skull or vertebras — or disease in the nervous centres 
themselves ; but also — when it is seated at the extremities, or in the 
course of nerves supplying parts whose action is associated with that 
of the part in question by a reflex action ; as when the diaphragm 
and other muscles of respiration are excited by irritation of the nares, 
or the former muscle thrown into spasmodic contractions by irrita- 
tion of the extremities of the pneumogastric nerve, in the case of hic- 
cough, where the offending cause is in the stomach : but further than 
this, we know from experience, that in irritable subjects, and in cer- 
tain morbid conditions of the system, convulsive or spasmodic move- 
ments may be excited in different parts of the system, by irritation 
propagated to the nervous centres from the parts where the irritation 
is set up, but thence reflected to parts not associated with the latter 



croup. 155 

by any normal reflex functions, as in the convulsions of children from 
teething or gastric irritation, and in tetanus. Hence we have ample 
ground for the explanation of the phenomena of the " child-crowing," 
"laryngismus stridulus," or "spasmodic croup." The crowing respi- 
ration and its accompanying dyspnoea, which are the most obvious 
phenomena of this disease, occur in paroxysms between which there 
are intervals of tranquil respiration. The best description of this 
affection is that given by Dr. Ley. " "When the closure of the chink 
of the glottis is not perfect (says he), the child struggles for breath, 
the respiration is hurried, the countenance generally bluish or livid, 
the eyes staring, and each inspiration is attended with a crowing 
noise. When the closure is more complete, the function of respiration 
is entirely suspended for a while; there is an effectual obstacle to the 
admission of air. The child makes vehement struggles, by some 
termed convulsive, to recover its breath. At varied intervals, from 
a few seconds up to a minute, or upon some occasions nearly two 
minutes, air is at length admitted through the glottis, now partially 
open, and this rush of air passing through a very narrow chink, pro- 
duces the peculiar sound. To these symptoms not unfrequently 
succeeds a fit of coughing or crying, which terminates the scene ; or 
if the glottis be not thus partially open, the child at the end of from 
two to three minutes at the utmost will be suffocated. Pallid and 
exhausted, it falls lifeless upon its nurse's arms, and it is then that 
the child is generally said to have died in a fit." It very often hap- 
pens that the above symptoms are attended by convulsion of the 
extremities, especially of that form often associated with gastric irri- 
tation in children, namely, the contraction of the muscles of the wrist, 
thumb, and fingers, and of the ankles and toes, the thumb being 
strongly contracted upon the palm, and the foot so distorted as to 
have almost the appearance of club-foot. 

The distinctive characteristics of this disease are the occurrence of 
the above symptoms, with the absence of fever and the perfect tran- 
quillity of the respiration between the paroxysms. The explanation 
of these phenomena need not detain us long as it is included in what 
has already been said of reflex nervous irritation, and, indeed, all the 
most satisfactory, which have been given, resolve themselves into this. 
That of Dr. Ley, for instance, wherein the temporary closure of the 
glottis is accounted for by pressure upon the recurrent, or some 
branch of the pneumogastric nerve, from enlarged glands in the 
neck, or within the chest, is but a particular instance of the general 
fact of pressure or irritation in the course of the eighth or fifth pair 
of nerves, inducing spasm of the glottis ; the same would apply to its 
being excited by offending matters in the stomach, or by the irrita- 
tion of teething ; and its arising from disease within the cranium, is 
but an instance of the cause of irritation existing at or near the origin 
of either of the same nerves. The presence, however, of enlarged 
glands in the neck may assist us much in the diagnosis of eases of 
this description, since not only may it be in itself the cause of dis- 
ease, but shows the probability of strumous disease either in the 
glands of the chest or abdomen, or within the brain itself; it also 



156 ceo up. 

indicates that state of nervous atony, in which irritation so produced 
upon these nerves would be most likely to excite the spasm of which 
we are speaking. 

The last mentioned variety of croup does not strictly belong to in- 
flammations of the larynx or trachea; neither is it for the most part a 
disease of those parts at all : we have, however, spoken of it in this 
place from its liability to be confounded with the true croup, and in 
order the better to consider the diagnosis of these affections. If it 
be borne in mind that croup is essentially an inflammation of the 
trachea, and that consequently the obstruction which it excites is 
to the breathing, and not to the deglutition, we shall have no great 
difficulty in distinguishing it from the cynanche tonsillaris, the cy- 
nanche maligna, and the cynanche pharyngea ; not to mention that the 
latter diseases may be recognized at once by an inspection of the 
throat, unless indeed, they are of sufficient severity to prevent the 
opening of the mouth, which would of itself be a sufficient sign of 
the existence of one of these rather than croup. The eruptive fevers 
(more particularly measles), and whooping-cough, sometimes commence 
with a degree of inflammation about the trachea, which excites a 
spasmodic cough, and is attended with a husky voice, not unlike that 
of croup, especially of the mucous kind ; in the case of the measles, 
the watery eye, the coryza, and the sneezing, soon point out the true 
nature of the case ; in whooping-cough the distinction is not at first 
so easily made, but the diagnosis is of no great importance, since the 
tracheal inflammation which really does exist, will require to be 
treated according to its severity ; and when the latter disease is really 
established, the character of the cough, so unlike that of croup, will 
at once mark the difference. The diagnosis from laryngitis is, per- 
haps, not easily made with certainty, though it is fortunately one 
of no great practical importance, since the treatment would be nearly 
the same in either case. It will assist us, however to remember 
that laryngitis is mostly a disease of adult life, whereas croup is 
one affecting almost exclusively infants and children. The fixed 
burning pain of laryngitis, which is always referred to the situation 
of the pomum Adami, will also assist us at the commencement of the 
latter disease ; and its further progress, unlike that of croup, leading to 
ulceration and suppuration, and scarcely ever to the effusion of false 
membrane, will enable us to recognise it in its more advanced stages. 
The chronic affections of the larynx and glottis, though they some- 
times produce the croupy cough, voice, and respiration, may never- 
theless be distinguished by their slower progress, and by their rare 
occurrence amongst children. (Edema of the glottis may indeed 
suddenly occur even amongst them, when there exists disease of the 
kidney with a tendency to dropsy ; but the presence of this latter 
disease ought at once to suggest the true nature of the affection. It 
is of the first importance not to mistake the earlier symptoms of 
croup for those of ordinary catarrh, but of this we have already 
spoken in describing the invasion of the former. Croup may super- 
vene upon bronchitis, when its presence may be detected by its cha- 
racteristic symptoms presenting themselves in addition to those of 



DIAGNOSIS. 157 

the latter disease ; but there can be very little danger of mistaking 
between the two, as we shall perceive when we come to treat of 
bronchitis. Symptoms not unlike those of cronp may be induced by 
the presence of foreign bodies in the larynx or trachea, the sudden- 
ness of the pain and suffocation, the change in the situation of the 
latter, the dryness of the cough, the violence and irregularity of 
strangulation, as well as the history of the case, will generally lead 
to the discovery of its true cause. 

The greatest practical difficulty in the diagnosis of croup used to 
be, that between the different forms of the disease, especially that 
between the plastic croup and the child-crowing. The more correct 
knowledge of the latter disease which we now possess, and the recol- 
lection of its characteristic symptoms as already described, will now 
remove all serious difficulty. It may, in fact, be distinguished from 
the true croup by the age of the patient, generally from nine to 
fifteen months, but never, according to Dr. Clarke, beyond the ex- 
piration of the third year of the child's life — whereas the true croup 
is the most common after that age •■ — by the history of the case, and 
condition of the patient, generally presenting some cause of nervous 
irritation, as teething, gastric irritation, enlarged glands in the neck, 
a strumous diathesis, or a large or ill-formed head ; — by the sudden- 
ness of the attack, and by its sudden departure ; — and by the ab- 
sence of fever, cough, and dyspnoea in the intervals between the 
paroxysms. 

The difference between the first and second varieties of croup is 
one rather of degree than of kind — the fever in the latter is slight ; 
it generally, too, attacks younger children than does the membranous 
croup, especially those who have lately been weaned. It should be 
remembered, however, that those children who have suffered from the 
true croup in early life are very liable to have such symptoms recur 
when they become the subject of a slight catarrh ; but it is equally 
true that such symptoms may run on to an attack of the real croup, 
and therefore require watching, and, if necessary, prompt but not 
violent treatment. 

As to the circumstances which conduce to a liability to true croup, 
it is pretty generally agreed that the greatest tendency to it exists in 
cold and damp situations, and particularly such as are liable to rapid 
changes of temperature ; those seasons of the year in which such 
weather may be expected are also those in which, in this climate, it most 
frequently happens, viz., from November to April. There is, how- 
ever, more difference as regards the character of constitution of the 
individual which is most liable to it, whence we may infer that but 
little is certainly known respecting it. Some consider that florid and 
irritable children are most liable to it ; thus Dr. Copland says, " the 
nervous and sanguine temperaments, or a mixture of them — the spas- 
modic' characters predominating in the former, the inflammatory in 
the latter — with a tendency to a fulness of habit, seem to predispose 
to croup." It should, however, be recollected that there is not neces- 
sarily a greater tendency to inflammation in those inclined to plethora 
than in others; although those of a nervous temperament arc un- 



158 croup. 

doubtedly more liable to nervine affections. It is certain, too, that 
in some families there exists a peculiar proneness to the disease, and 
that in certain seasons it prevails almost epidemically, though there 
is no ground for believing that it is ever contagious. 

Those children who have once suffered from croup have a greater 
tendency to the disease than others, in addition to the liability to 
croupy symptoms upon the occurrence of trifling irritation. 

The mucous form of croup is influenced by the same external cir- 
cumstances as the more severe form of the disease ; it more com- 
monly, however, attacks children of a leuco-phlegmatic temperament, 
and languid circulation. The external circumstances which seem 
the most to favour the attacks of the child-crowing or true spasmodic 
croup, are damp and low situations, the want of pure air, of light, 
and of wholesome diet; whatever, in fact, interferes with healthy 
nutrition, and the perfect elaboration of the blood, the disease being, 
in truth, one that particularly affects scrofulous children. It is by no 
means improbable that exposure to cold and damp, or to any of the 
causes which in stronger children induce the ordinary croup, may 
bring on an attack of child-crowing in those in whom, owing to a 
state of constitution of the character just described, there exists a pre- 
disposition to it ; but the common exciting causes of the disease are 
those mentioned in the description of it, namely, irritation existing 
either at or near the base of the brain, or along the course, or at the 
extremities of the fifth or eighth nerves. 

As croup is at all times a very dangerous disease, the general prog- 
nosis must be unfavourable, or at the best extremely doubtful ; though 
in a child of good constitution, and in the early stages, we have a fair 
chance of success from a well-directed and persevering plan of treat- 
ment. The danger, however, is always very great, when from a 
sibilant respiration over the larger bronchial tubes, we have reason 
to believe that the inflammation has extended to them. We must 
also be exceedingly cautious in pronouncing our little patient out of 
danger, for as long as there exists any false membrane in the trachea, 
or even that excessive sensibility and irritability of the part which 
are the consequences of this inflammation, there is a possibility of 
obstruction, or of spasm of the glottis. The expulsion of a mem- 
branous substance, if followed by a warm healthy perspiration, and 
relief to the respiration, is at all times a favourable symptom ; whereas, 
the increased length of the paroxysms of dyspnoea, with diminution 
of the interval between them, the failing pulse, lividity of counten- 
ance, and clammy perspiration, with the other symptoms already 
mentioned as indicative of the last stage of the disease, can be re- 
garded in no other light than as signs of the greatest danger, if not 
of impending death. The mucous croup, as long as it continues such, 
is not a disease of much danger ; but even here our prognosis must 
be very guarded, as it may speedily pass into the severer form of the 
disease, and it is upon its tendency to do so that its danger depends. 

The child-crowing, though merely a spasmodic disease, is not upon 
that account to be regarded as free from danger, for not only may 
death, as we have seen, take place by suffocation during the paroxysm, 



TREATMENT. 159 

but the long suspension of the respiration may give rise to conges- 
tion, leading to serious disease in the brain, lungs, or heart. 

The first object in the treatment of croup should be to check the 
inflammation, and thus, if possible, arrest the disease, and prevent the 
formation of the inflammatory product, constituting the false mem- 
brane, or albuminous deposit obstructing the air-passages. If, how- 
ever, we are too late, or unable to effect this, we must endeavour to 
induce the removal of these inflammatory products ; and thirdly, we 
must endeavour to allay the nervous irritability upon which the 
spasm attends. 

The most effective means at the commencement of the disease for 
fulfilling the first of these indications, is an emetic sufficient to pro- 
duce full vomiting ; for this purpose the tartar emetic is to be pre- 
ferred to ipecacuanha, though, perhaps, it may be better to use a 
combination of both : thus from a quarter of a grain to a half a grain 
of the former, with from three to twelve or fifteen of the latter, ac- 
cording to the age of the child, will generally produce full vomiting, 
the consequence of which will often be the expulsion of thick glairy 
mucus, and in some cases of shreds of false membrane, followed by 
free diaphoresis, and great relief to the respiration. The relief fol- 
lowing the exhibition of the emetic is sometimes so great as to lead 
to the belief that the affection has been entirely spasmodic ; but the 
effect of an emetic, even at an advanced period of the disease, is some- 
times so striking as to leave no doubt of its efficiency in cases un- 
questionably inflammatory. It is only in the commencement, and 
when it is somewhat doubtful whether the attack will prove one of 
the more severe membranous form of the disease, or of the second 
and milder one, that an emetic should be trusted to as the primary 
remedy, and before bleeding has been performed either locally or 
generally. When, however, the patient is seen thus early we may 
have recourse to it in the first instance with a fair chance of success. 
It should be observed, moreover, that there is generally a great 
tolerance of emetics, and that much difficulty is often experienced in 
effecting vomiting ; and when this is the case, it will be well to repeat 
the emetic, though in a smaller dose, perhaps half that administered 
in the first instance, at the end of an hour's time. The vomiting, 
when it has been obtained, will commonly be followed by free action 
of the bowels. When, however, this does not take place, measures 
should be taken to ensure it, as most marked relief often follows free 
purgation ; a very good practice will often be to keep up a slight 
degree of nausea, and moderate action of the bowels by a combina- 
tion of tartar emetic and sulphate of magnesia; after the disease has 
yielded to these measures, slighter spasms will frequently occur, and 
these will be best met by the application of flannel cloths wrung out 
in hot water, so hot as to produce great redness, or even a slight 
degree of vesication. 

When, however, as most commonly happens, the patient is not 
visited for many hours after the attack, and there are reasons from 
the symptoms to believe that the second stage, that, namely, ol' mem- 
branous effusion, has already commenced, or is upon the point of 



160 ' CEO UP. 

doing so, we must not delay to abstract blood in such quantities as 
the degree of fever, the sharpness of the pulse, and the age and con- 
stitution of the patient seem to call for or to justify. In children 
above the age of four, or sometimes even younger, we may often 
practice venesection with tolerable ease and success, sometimes by 
opening a vein in the back of the hand, and where this mode of ab- 
stracting blood is practicable it is to be preferred at this stage of the 
disease in its severer forms, as the effect produced upon the system 
is more speedy and more certain, and the quantity of blood drawn 
can be more accurately estimated ; for a child of three years four 
ounces will be a pretty full bleeding, and an ounce may be added for 
every additional year. In older children, or where it is not practica- 
ble to open a vein, cupping between the shoulders may be practised 
with advantage, the same rule as to the quantity of blood taken 
being observed as in venesection. In speaking, however, of these 
rules, we ought to premise that they are only approximations or 
averages, and that much must be determined by the fever, and appa- 
rent strength of the individual child. In infants and very young 
children, where we are obliged to have recourse to leeches, we may 
observe nearly the same rule ; thus Dr. Watson recommends " the 
application of a couple of leeches to an infant in its first year, and an 
additional leech may be employed for every additional year." These 
leeches should also be applied over the first bone of the sternum (not 
above it, and along the course of the trachea, as is recommended in 
some works); since independently of the objection stated in speaking 
of the use of leeches in laryngitis, we ought in no case to apply 
leeches in children where we should be unable to apply pressure to 
stop the bleeding when necessary, in fact we ought not wantonly to 
neglect this precaution in patients of any age. 

After the bleeding as recommended above, we should, before re- 
peating it, have recourse to emetics and purgatives, which may be 
employed much in the manner already described when speaking of 
their employment in the first instance, and here, as before, it will be 
expedient to administer a purgative, in the form perhaps of calomel 
and jalap, if the same effect have not been produced by the emetic. 
It will be afterwards desirable to keep up the nauseating and depres- 
sing effect of the antimony upon the system ; as by so doing we 
diminish the force of the heart's action, and probably also the activity 
of the capillary circulation, and thereby, the supply of blood to those 
vessels whence the effusion of the membranous matter takes place ; 
the best mode of affectino- this is to administer the tartar emetic at 
moderately short intervals. About a quarter of a grain in a desert- 
spoonfull of water may be given every hour to a child of six years, 
and the frequency and quantity increased or diminished according to 
the effect produced both as regards the nausea, and the force and 
frequency of the pulse. The failure of the strength of the pulse will 
generally be attended with relief to the difficulty of bleeding, but if 
with the returning force of the former the latter return also, recourse 
must again be had to the antimony ; the collapse induced by which 
remedy is often so great as to threaten extinction of life, in which 



TREATMENT. 161 

case a little brandy, or a few drops of sp. amnion, co. should be admi- 
nistered. About a grain of calomel may at the same time be given 
every three or four hours. It may be well to remark, however, that 
many of the best authors recommend the exhibition of this remedy 
in larger doses, and some the combination of it with the antimony in 
the form of powders, but the antimony appears to be the remedy, 
which, of all others, has the most powerful effect upon inflammations 
of the mucous membranes, and therefore it is better to administer it 
in the form which will be most readily and certainly taken : and this 
it will be in solution, since from being tasteless it may be given to a 
child of any age as a drink, without his being aware that he is swal- 
lowing medicine, whereas there is often much difficulty in the admi- 
nistration of powders, and the struggling which attends the forcing 
them down is injurious. We would not, however, be understood as 
setting no value by the use of calomel, it probably diminishes the 
tendency to the effusion of the membranous matter, and perhaps, 
where it has taken place, it favours its separation. It is therefore 
best to rely mainly upon the known beneficial effects of the tartar 
emetic, and at the same time, where it can be done, to administer the 
calomel as an auxilliary remedy. In older children, the Dover's 
powder, in doses of about a grain, or a grain and a half, may be 
combined with the calomel, and in younger, a little extract of 
conium, or of hyoscyamus may be given in the mixture, disguised 
with a little syrup, provided only it can be readily administered, as 
any excitement in swallowing it would more than counteract the 
good effect of the anodyne. An admirable sedative, however, in the 
paroxysm of dyspnoea will be the use of the hot fomentations already 
recommended. Blisters are on every account objectionable. A 
most important adjuvant in the treatment of croup is the keeping the 
apartment at a steady temperature, about 65° Fahr. ; the child should 
also be kept as quiet as possible, and when he is sufficiently old or 
intelligent should be urged to refrain from speaking. 

When the symptoms are those of impending suffocation, the pros- 
pect may be inferred, from what has been stated already, as nearly 
hopeless. Cases of this kind, have, however, sometimes, though 
rarely, recovered under the use of squills and ammonia, with conium 
or henbane, and a little wine ; but the symptoms are most generally 
fatal. The question remains then, are we in such cases to endeavour 
to save the life of the patient by the operation of tracheotomy ? : not 
only theory but experience also is against the probability of success 
from such an operation, and were it not for its having succeeded in 
two or three well authenticated cases, it might be pronounced an 
unjustifiable operation. It has, however, succeeded in this very small 
number of cases, but it has failed in numberless others. The reason 
of the very small success which has attended this operation in croup, 
compared with that which has resulted from it in laryngitis, is not to 
be found in the greater difficulty of the operation in children than in 
adults (though that is not to be altogether disregarded), since it has 
been performed with safety and success in cases of inflammation of 
the larynx caused by boiling water or irritating fluids, and also with- 

11 



162 ceo up. 

out any serious result in cases of supposed membranous croup, but 
upon the fact of the membranous effusion most commonly taking 
place in the trachea, and along the course of the bronchial tubes, 
reaching even to their finer ramifications. The only cases in which 
it can succeed are the very rare ones where the false membrane does 
not extend more than half an inch below the cricoid cartilage ; and 
those in which there is little or no false membrane, but the impedi- 
ment to the breathing has arisen from thickening of the mucous 
membrane, and accumulation of viscid, reddish mucus, (which often 
occurs in the mucus form of croup) about the narrowest part of the 
trachea, which accumulation cannot perhaps in some cases be ex- 
pelled from the impossibility of getting air enough behind it to force 
it out. These are conditions the existence of which it is unfortu- 
nately next to impossible to ascertain. Where, however, mucous 
croup comes on very suddenly, characterized by the croupy voice 
and speedy threatening of suffocation, it is probable that the disease 
does not extend far down the larynx, and the operation may be per- 
formed, the best excuse for which is that if it afford but a bad chance, 
it is almost the only chance. 

It may be well again briefly to recapitulate the chief points in the 
treatment of this formidable disease. At the commencement, in 
children who are not very robust, endeavour at once to arrest its 
progress by emetics of potassio-tartrate of antimony, followed by 
nauseating and depressing doses of the same medicine, and if neces- 
sary by a purgative. In more robust children in the country, and 
when the disease is verging on the second stage, bleed and then 
adopt the same plan, adding the calomel, and if the disease continue 
to resist this mode of treatment, and the antimony appears to depress 
more than is consistent with safety, push the calomel. If all other 
remedies fail, and suffocation appear imminent, tracheotomy is admis- 
sible or rather justifiable, though only when there is no apparent 
hope from any other course, not that the operation is in itself a very 
dangerous one in skilful hands, but for the reasons assigned above, 
and also because in cases where it is not called for by the imminent 
suffocation, the irritation of the trachea which must attend it, as well 
as the direct admission of cold air into that tube, cannot but aggra- 
vate the existing inflammation ; it is on this account essential, when 
the operation is resorted to, that the temperature of the room should 
be raised to 80° or 85° Fahr., and the air kept tolerably moist by the 
presence of vessels of warm water, exposing a considerable surface 
for evaporation. 

The treatment of the spurious or spasmodic variety may be inferred 
from what has been said of its cause; it will, however, be more fully 
understood when we have spoken of those diseases of which it is in 
reality but one of the symptoms ; attention to the gums is the first 
consideration, and if they are swollen, or if there are any teeth nearly 
through, they should be freely lanced. The state of the alimentary 
canal should also be carefully investigated, and moderate doses of castor 
oil or of rhubarb and magnesia administered if there be reason to ap- 
prehend the presence of irritating matter, purging is, however, to be 



TREATMENT. 163 

carefully abstained from. The cervical glands mnst next be attentively 
examined, and if enlargement be found we have not only detected a 
condition which may, of itself, be an exciting cause of the spasm, but 
which also points to the probable existence of other causes in enlarged 
bronchial or mesenteric glands, as also to a strumous condition of the 
system, which is one highly susceptible of this affection. Lastly, we 
must carefully examine the head, and inquire diligently into all cir- 
cumstances which would indicate disease of the brain or of its mem- 
branes. We see, then, that the treatment of this disease involves not 
only that of dentition and gastric irritation, but also that of the 
strumous diathesis, and of the diseases of the viscera of the head, 
heart, and abdomen. 

During the paroxysm a warm bath will often prove serviceable, or 
what is still better, the application of a sponge from which hot water 
has first been squeezed, or of flannels wrung out in hot water. It 
may be well too here to suggest, in addition, the treatment applicable 
to the particular lesion which is supposed to be at the root of the 
mischief, that nervine tonics and anti-spasmodics are specially indi- 
cated, and for this purpose the sulphate of zinc with a few drops of 
tincture of valerian, or the valerianate of zinc, are particularly appro- 
priate. It may be well also to reiterate what has before been 
observed, that a certain amount of inflammation about the larynx or 
trachea may be the cause of the spasm, and therefore that we are not 
hastily to discard all antiphlogistic remedies merely because the dis- 
ease does not present the unequivocal symptoms of membranous or 
even mucous croup. 



164 CATARRH AND BRONCHITIS, 



XI. 

CATAEEH AND BECMCHITIS. 

The catarrh, common cold, or "cold in the head," is a disease so 
frequent in this country, that there can be very few, if any, who have 
escaped it altogether, and no great number who ever pass through a 
year, without suffering an attack of greater or less severity. Any 
lengthened notice of it must, therefore, be superfluous, although the 
mention of it cannot be altogether omitted, since it is intimately con- 
nected with important diseases, from which it is not at all easy to 
distinguish it. 

Catarrh is essentially an inflammation of the Schneiclerian mem- 
brane, and the mucous lining of the nares, extending thence upwards 
to that of the frontal sinuses, and through the lachrymal ducts to the 
conjunctiva ; posteriorly to the posterior fauces, and along the 
Eustachian tubes ; and downwards to the trachea and large bronchi. 
It is commonly preceded by lassitude, and pains or aching in the 
back and limbs ; not, indeed, often of sufficient severity to excite the 
apprehension of severe illness, but a general feeling of malaise. 
These are quickly followed by a sense of weight and tightness across 
the forehead, soreness or weakness in the eyes, stuffiness, or obstruc- 
tion in the nares, an uneasy feeling about the situation of the 
Eustachian tubes, and some soreness about the throat, and hoarse- 
ness or loss of voice, often with pain about the muscles of the neck ; 
the tongue is also somewhat furred; there is thirst, and increased 
sharpness and frequency of the pulse. As yet there is no coryza or 
increased secretion from any part of the inflamed mucous membrane; 
we have, in fact, the signs of engorgement or active congestion which 
constitutes the first stage of inflammation, and in which, as we have 
already observed, there is swelling, at the same time that the natural 
secretion of the part is generally arrested or diminished ; hence we 
have the feeling of tightness and obstruction in the various passages 
lined by this membrane, and frequently, a wish to expel something 
from the nares, although the sensation indicating its presence is 
attributable solely to the turgescence of the inflamed membrane ; 
one consequence of this state of things is repeated sneezing. 

In pure catarrh, as distinguished from bronchitis, the inflammation 
does not extend into the bronchial tubes, and, therefore, there are no 
abnormal respiratory sounds belonging to it as such, we consequently 
reserve our remarks upon the stethescopic signs of inflammation of 
the bronchial membrane till we come to treat of those diseases of 
which it properly forms a part. 

The symptoms above described, which are those of what may 
be termed the first stage of catarrh, generally continue about two 
days, when the characteristic effusion of inflammation begins to 
show itself ; this, in the case of a mucous membrane, consists in an 



SYMPTOMS — CAUSES. 165. 

increase in its secretion, but there is at the same time an altera- 
tion in its character; it is not of the bland nature which belongs to 
it in health, it is serous, transparent, and glairy, and, from its acrid 
character, often excoriating the upper lip, constituting the corjza or 
excessive discharge from the nostrils, attended with frequent sneezing. 
There is often at the same time profuse lachrymation, whilst the 
fauces, velum, and uvula pour forth a like discharge, which irritates 
the glottis, and produces a short quick cough. During this period 
of the disorder, there remains more or less thirst and fever, and the 
appetite is commonly impaired. 

This condition generally continues about forty-eight hours, and is 
the period during which the "cold" is most annoying to the patient; 
at the end of that time, if allowed to run its course, it passes into the 
third and last stage. The characteristics of this are a subsidence of 
the uneasy feelings dependent upon the turgid state of the mem- 
brane, and the irritating discharge from it, a cessation of the fever, 
and the pouring out of a secretion, of a thicker consistence, as well 
as more copious, than occurs in the healthy state. It consists, in this 
instance, of a bland, opaque, tenacious mucus, which is freely excreted 
from the nostrils, and often collects in the posterior nares and fauces, 
whence it is expelled in lumps of tough tenacious phlegm of a green- 
ish or yellowish colour; as this proceeds the inflammation and irri- 
tation subside, and if the patient be not exposed to any cause likely 
to produce it afresh, the disease disappears in a few days. 

u There is another form of catarrhal complaint, which has hitherto 
excited little notice, but which merits attention, not because it is in 
itself of a character to inspire the least alarm, but because it may be, 
and probably often has been, a source of much uneasiness, in conse- 
quence of being mistaken for something else. In this instance, the 
inflammation appears to be chiefly confined to the internal mouth, 
constituting what may be called catarrhus stomatitis. The whole of 
the mucous membrane appears highly injected, and sometimes slightly 
aphthous, the gums are red, swollen, and tender ; there is occasionally 
a slight fulness about the parotids, and not unfrequently a greater or 
less degree of salivation; indeed, in some instances, the salivation 
has been profuse, and has been accompanied by a foetor exactly re- 
sembling that arising from mercury. There is some, but seldom 
much, constitutional disturbance, and the patient generally gets well 
in a few days."* 

The circumstances which are commonly said to predispose to ca- 
tarrh, but which, speaking more correctly, render the individual 
more than ordinarily susceptible of its usual causes, are a peculiar 
idiosyncrasy, the nature of which is not accurately understood — a 
delicacy and irritability of habit, often induced by overmuch indulg- 
ence, living in overheated apartments, and neglecting the bracing 
effects of fresh air, from a dread of the very evil which is thus ren- 
dered more probable, and perhaps more than all preceding attacks. 
The most common of the so-called exciting, or really direct causes, 

* Bright and Addison, "Elements of the Practice of Medicine," vol. i., p. 172. 



166 CATARRH. 

are, sudden exposure to cold, as to draughts of cold air, sudden 
changes of temperature, either from heat to cold, as in going from a 
heated drawing-room into the cold outer air, or coming in from a 
cold drive and sitting before a fire in a warm room; getting wet 
through, or wet-footed. Some persons are liable in the hay season to 
a modification of catarrh, known as hay -fever, and which is ascribed 
to something emanating from the flowering grass. A disease of 
which one of the most prominent symptoms is catarrh, has, on several 
occasions, prevailed epidemically over a large portion of the globe, 
under the name of influenza, or epidemic catarrh ; it is, however, as 
the experience of 1833, 1837, and above all of 1847-8, must have 
taught us, too formidable and fatal a malady to be thus lightly passed 
over, and must be reserved for a separate notice. 

The prognosis of catarrh, as such, is of course generally favourable : 
the symptoms of catarrh are, as we have seen, sometimes the only 
ones which present themselves at the commencement of that formida- 
ble disease, the croup ; and a neglected catarrh often extends along 
the bronchial membrane, till it becomes a severe bronchitis ; but the 
prognosis is in that case the prognosis of the latter disease. It is 
also to be borne in mind, that, in persons disposed to phthisis or 
asthma, neglected or repeated attacks of catarrh are often the means 
of calling the morbid tendency into activity. 

As regards the treatment of catarrh: it is not very often that this 
disease becomes the subject of our remedies. In almost every family 
there is some favourite preparation or regimen which is put in prac- 
tice on such occasions. In general, rest in an equable temperature, 
with a light diet, and abstinence from stimulants, and the avoidance 
of the circumstances which excite the disease, will prove sufficient 
for a cure, or, at all events, allow of recovery in a few days. A 
catarrh may, however, be often cut short, or its duration greatly 
shortened, by appropriate measures at the commencement ; although 
the means which have been recommended are very different, and 
may seem opposite to each other. The safest and best plan, perhaps, 
when we are consulted early, is to advise a foot-bath, and going early 
to bed, a few grains of comp. ext. of colocynth, with a sixth of a grain 
of tartar emetic, and three of ext. of hyoscy., with a moderate saline 
aperient in the morning ; and a mild diaphoretic draught, as three 
drachms of liq. am. acetat., with about a half a drachm of sp. seth. nit. 
and ten or twelve minims of vin. ant. pot. tart, or vin. ipecac, in cam- 
phor mixture, three or four times daily. A continuance of this plan 
for two or three days, the drink being slops, the diet boiled mutton, 
with a light bread pudding, will generally effect a cure. 

A mode of cure, not perhaps more agreeable, but having the ad- 
vantage of not confining the patient to the house, is recommended 
by Dr. Watson upon the authority of Dr. Williams; it has been 
termed the dry plan of cure. It consists in abstinence from every 
kind of drink. " ISTo liquid, or next to none, is to be swallowed until 
the disorder is gone. The principle here concerned is that of cutting 
off the supply of the watery materials to the blood." Dr. Williams 
"allows, without recommending, a table-spoonful of tea or milk for 



TREATMENT. ; 167 

the morning and evening meals, and a wine-glass of water at bed- 
time." This plan has certainly* the merit of simplicity, its novelty is 
not so certain. "In gravedine autem," says Celsus, "primo die qui- 
escere neque esse neque bibere, caput velare, fauces lana circumdare: 
postero die surgere, abstinere a potione, aut si res coegerit non ultra 
heminam aquas assumere."* Opposed to this is the more grateful 
moist cure, viz., about four glasses of sherry with sugar in a large 
quantity of warm water, light reading on the sofa for the evening, a 
foot-bath and early to bed ; or the still more agreeable one of a good 
dinner and an extra glass or two of wine. The first of the two latter 
expedients will often prove effectual in the commencement of the 
disorder, but should never be put in practice when much fever is 
present; the latter should only be ventured upon in the more ad- 
vanced stage, when the mucous excretion is thick and readily ex- 
pelled. 

A most important matter in connection with catarrh, is prevention. 
Now there are various means attempted for this; one is to heap 
flannel jacket upon chest- warmer, and outer garment upon outer gar- 
ment over this, till the patient perspires freely under the weight of 
artificial integuments, and thus a free action of the skin, the best 
relief to the internal mucous membrane, is kept up ; but if in an un- 
guarded moment he expose himself to a draught of air, or keen east 
wind, with a greatcoat too little, his enemy is sure to seize the op- 
portunity. A more rational mode of prevention, is that of enabling 
the system to withstand the impressions of cold, by inducing such a 
vigorous state of the circulation as may counteract its effect on the 
temperature of the surface, or quickly restore the heat that is lost. 
The habitual exposure to variations of temperature, as in exercise in 
the open air, blunts somewhat the sensibility of the surface, and ex- 
cites and strengthens the capillary circulation there ; and the same 
end is attained by the exposure of the surface to a temperature lower 
than it is likely to be called upon ordinarily to encounter, but for so 
short a time as to avoid the danger of any ill effects from it. This 
may be done by cold bathing or sponging, or the use of the shower- 
bath. The latter of these has no doubt an excellent effect in ena- 
bling the system to resist impressions of cold, but it is liable to grave 
objections in many cases. In the first place there is not in all per- 
sons sufficient strength to withstand the shock, or, in other words, 
sufficient power in the moving forces of the circulation, to restore 
activity in the capillaries of the surface, when it has been thus sud- 
denly arrested, and in such cases there is no reaction or " glow" after 
the effusion, but, on the contrary, a chilliness, which is a certain sign 
that harm rather than benefit is the consequence. But we must also 
remember, that even where, to all appearance, a healthy reaction in 
the superficial capillaries follows the use of the shower bath, there is 
a considerable stress thrown upon the ventricles of the heart, and that 
in persons of lax fibre, there is danger of some injury being inflicted 
upon this organ or its valves. Those too who are liable to any undue 

* Lib. iv., cap. ii. 



168 % BRONCHITIS. 

flow of blood towards the head, as indicated by head-ache with in- 
creased heat of the scalp, ought not to use the shower-bath, since the 
first and most powerful shock takes place upon the surface of the 
head, and the subsequent reaction there is consequently greatest. 
Persons, therefore, of languid circulation, of feeble muscles, or dis- 
posed to determination towards the head, ought not to use the shower- 
bath. The slipper bath may be begun to be used with tepid water, 
in summer, and afterwards, by degrees, with cold ; and thus many 
persons may be inured to its use, who would shudder at the very 
mention of cold water. There is, however, much trouble attending 
the use of this bath, and therefore it cannot be very generally em- 
ployed ; but there are few who cannot procure the luxury of a large 
tub or pan, in which they may sponge themselves, beginning with 
the extremities, then freely sponging the abdomen, chest and back, 
and last the head, a practice which will have the prophylatic ad- 
vantages of the shower-bath, without the risk either to the heart or 
the head. 



BEONCHITIS. 

"We have dwelt somewhat at length upon catarrh, not so much on 
account of its importance considered by itself, as from its liability, if 
neglected, to lead to the more formidable disease bronchitis, or in- 
flammation of the mucous membrane of the bronchi and their rami- 
fications through the lungs. This disease is one of such frequent 
occurrence in this climate, that but few persons pass through life 
without one or more attacks of greater or less severity, and although, 
in ordinary cases, it is attended with little or no danger, in those of 
its greatest severity it is one of the most formidable diseases which 
we are called upon to treat ; as, besides the more imminent peril of 
this latter class of cases, the remote consequences are to be carefully 
guarded against in all, since they include some of the most dangerous 
lesions, not only of the bronchial tubes and lungs, but also of the 
heart and liver, and through them of the kidneys and brain. 

Bronchitis usually commences with the ordinary symptoms of in- 
flammatory fever. There is considerable lassitude, pain in the limbs 
and back ; the tongue is furred and rather disposed to be red at the 
edges; nearly at the same time, or very shortly afterwards, the 
character of the disease is announced by a feeling of irritation about 
the throat, with a sense of oppression which is mostly referred to the 
situation of the sternum, and gradually assumes the character of a 
rawness or even sharp pain, aggravated by coughing or taking a 
deep inspiration : the cough is short and frequent, and there is com- 
monly at this period of the disease no expectoration, but the respira- 
tion is hurried, and performed with increased effort. As the disease 
advances, there is more decided febrile reaction, which in some cases 
is of great severity ; the skin becomes hot, often dry, especially in the 
commencement, though sometimes it is moist throughout, the tongue 
is furred on the dorsum, but red at the tip and edges, and the papillae 



SYMPTOMS. 169 

commonly elongated; there is thirst and often headache, scanty urine, 
a frequent, full, but compressible pulse. With the increase of the 
fever there is commonly an aggravation of the cough and dyspnoea ; 
the cough being frequent and sometimes violent ; and the respiration 
not only hurried, but accompanied with wheezing, and causing pain 
often of a sharp character, referred chiefly to the sternum, though 
often extending to different parts of the chest ; but there is not as 
yet, necessarily, any expectoration. 

The disease may now be said to have completed its first stage, and 
it may be well to consider for a moment the pathology of this period 
of bronchitis, both for the explanation of the symptoms and the right 
understanding of the changes which may be expected to follow. 

Bronchitis consists, as has been already stated, of an inflammation 
of the mucous membrane which lines the bronchi, and their ramifica- 
tions in the lungs ; and the first effect of inflammation of a mucous 
membrane is an increase in the quantity of blood in the vessels 
ramifying immediately beneath the surface, with often some serous 
effusion into the areolar tissue, but a diminution rather than increase 
in the secretions of the surface itself. Now the effect of this state of 
things upon the bronchial tubes must be a swelling and dryness of 
the lining membrane, accompanied with heat and pain; conditions 
which fully account for the sensations which have been described as 
felt in the chest ; at the same time that the tenderness of this mem- 
brane, which must render the inflation of the lungs painful, explains 
the distress with which the inspiration is accompanied. 

There is, however, another aspect in which it is of practical im- 
portance to view this change in the mucous lining of the bronchi, 
and that is in its effects upon the physical or auscultatory phenomena 
of the chest. Now as regards the sounds elicited by percussing the 
chest, we know that the quantity of air in the cells of the lungs is 
not necessarily affected by this condition of the mucous membrane 
of the tubes, and consequently we should not anticipate that any 
great alteration would take place in the resonance; and experience 
shows the same thing, for we find, coeteris paribus, that the resonance 
of the chest does not vary from what it is in health. 

Let us now examine the effect which the above change in the tubes 
must produce upon the sounds of respiration. We have already 
(p. 130) described the sound produced by the air entering the cells of 
the lungs, and have pointed out that in health no sound is to be 
heard at the surface of the chest, from the passage of the air along 
the tubes, except in certain situations, namely, over the first bone of 
the sternum, and on the space between the scapulas (p. 134); but if 
the tubes undergo the changes which have just been described, and 
their calibre is narrowed, and that irregularly, we shall have them 
converted into musical instruments, and hissing- whistling, cooing or 
snoring sounds may be expected to arise according to the degree in 
which the canal may be diminished, and to its diameter on each side 
of the obstruction, and this is what we actually find to be the case. 
We hear on listening to the respiration in this stage of bronchitis 
two classes of sounds, the one which might be supposed to arise from 



170 BEONCHITIS. 

the propelling air through, small tubes, and includes the hissing, 
whistling, wheezing noises which are included in the technical term 
sibilus • and the other comprising the cooing, snoring, croaking 
sounds which are denominated by the term ronchus. These are 
the bronchial dry sounds of respiration; and it is very important to 
become familiarly acquainted with them by experience, and to have 
correct ideas as to their cause. The various modifications of ronchus 
are such as would be produced by blowing through a cylindrical 
tube of some size, the bore of which is narrowed at any particular 
part, the note or tone depending upon the size of the tube, and the 
degree of obstruction. Ronchus thus belongs to the larger tubes, 
and is produced by partial narrowing of those tubes, either from 
the thickening of the lining membrane above described, or from the 
pressure of a tumour, or other morbid enlargement external to the 
tubes, or, which is very common, from the partial clogging of a tube 
by a piece of tough phlegm, such as might readily lodge in one of 
them when the moisture on the surface of the lining membrane is 
diminished. The first and last only of these conditions indeed belong 
to bronchitis; it is, however, necessary to remember that they may 
all equally produce a sound which has been too often stated to be 
peculiar to the latter disease. 

When again air is forcibly blown through a very small tube, we 
have a hissing sound, especially if there is any narrowing or con- 
striction in its course ; now this is precisely what aecurs when the 
inflammation has reached the lining of the smaller bronchial tubes, 
and rendered it tumid ; the occurrence, then, of a sibilant noise in 
bronchitis, shows that the disease has extended to the minuter bron- 
chi; and when it is heard over a very large portion of the surface of 
the chest, it indicates disease of a very formidable character. 

We have, then, two classes of dry sounds, the ronchus and sibilus, 
the former produced in the large, the latter in the minute tubes com- 
municating with the vesicles : now the ronchus, which is produced in 
the larger tubes, cannot very materially interfere with the production 
of the respiratory murmur, but when it is present to a great degree, 
it may prevent our hearing it by its own louder noise ; it outroars it, 
as Dr. Watson well observes; where indeed ronchus has been pro- 
duced in a large tube, by a piece of tough mucus partially obstruct- 
ing it, this obstruction may sometimes become complete, and then 
the ronchus and the respiratory murmur in the part of the lung to 
which the tube leads, will cease together ; we shall then have silence 
over that portion of the chest, but without any diminution of the 
resonance on percussion. This phenomenon, however, is not perma- 
nent, and may commonly be removed by coughing, and in this way 
it may be distinguished by its transitoriness from the same condition 
produced by emphysema. With the sibilant noises, however, the 
case is somewhat different ; for when the mucous lining of the 
minuter tubes is swollen, the ordinary murmur of the air passing 
from them into the cells must be converted into a hissing noise, so 
that the morbid sound supersedes rather than masks the natural one, 
whereas the sibilus which, under this condition of the small tubes, 



PHYSICAL SIGNS. 171 

attends the respiration, is altogether a new sound. Such, then, are 
the dry sounds indicating the first stage of inflammation of the large 
and small tubes respectively: we have described them separately, in 
order to their better explanation; but we as frequently meet with 
them combined as singly. It is more common, however, to have 
ronchus without sibilus than the latter without the former. When 
they coexist, we have every possible combination of groaning, snor- 
ing, cooing, hissing, and whistling. 

After a time, varying from one or two to several days, or even a 
week, but generally a very short time, the inflammatory secretion 
begins to show itself, first of all in the form of a glairy mucus, of 
considerable viscidity and tenacity, and whilst this continues the 
fever remains intense, and the dyspnoea, where a great extent of the 
membrane is involved, distressing; the disease being, in fact, at its 
height. The presence, however, of this secretion in the tubes causes 
a considerable alteration in the stethoscopic signs, the sounds which 
attend the respiration being now of the moist kind, which we pro- 
pose to designate rattles. It may, however, here be remarked, that 
though there is much force in the ojection urged by Dr. Watson 
against the term mucous rattle, adopted from the French, as descrip- 
tive of the moist sounds of bronchitis, viz., that we cannot tell by the 
sound itself that it proceeds from mucus rather than any other liquid 
in the air-passages, still the term rattle has been retained, as distinc- 
tive from the dry sounds of the tubes ronchus and sibilus, and as 
preferable to the term "crepitation," with which Dr. Watson pro- 
posed to replace it, and which appears best fitted to express another 
class of sounds to be described hereafter. By this term rattle, then, 
we mean the sound produced by the rapid formation and bursting of 
air-bubbles, caused by the passing to and fro of the air through the 
bronchial tubes loaded with fluid, whether this fluid be the glairy, 
viscid secretion of the first stage of bronchitis, of which we are now 
speaking, or, more fully formed mucus, puriform fluid, serous exuda- 
tion, or even blood. Corresponding to the ronchus, or dry sound in 
the large tubes, we have the large rattle, formed, apparently, by the 
greater size of the bubbles (rale musqueux a grosse bulks of Laennec) ; 
and, to the sibilus, the small rattle, arising from the smaller size of 
the bubbles formed in the minuter tubes. These sounds have been 
described separately, as it is of practical importance to attend to the 
difference between them, as well as the almost opposite conditions of 
the mucous membrane, which they indicate. It generally happens, 
however, in practice, that the dry stage of the inflammation does not 
continue long throughout its whole extent, but is in many parts 
speedily succeeded by that of increased secretion, giving rise to the 
various rattles, so that, in fact, we most commonly hear the dry 
sounds, ronchus and sibilus, coexisting in the same lung with the 
large and small rattles. Here, too, it may be observed, that we have 
described these rattles once for all ; we shall have occasion to recur 
to them hereafter in other diseases, in which, though their patholo- 
gical import may be different, their mechanical or physical cause is 
the same. 



172 BKO^CHITIS. 

The glairy transparent mucus, which is the first secretion poured 
out in acute bronchitis, marks, as we have said, the height of the 
inflammation , and it is important to watch the changes in the expec- 
torated matter, as from it we may learn the probable progress of this 
disease : when this is favourable, the sputa lose their transparent cha- 
racter, become of an opaque white, without, however, losing their 
stringy mucous character (but, on the contrary, rather increasing in 
consistency than diminishing in adhesiveness) ; and subsequently 
they often acquire a greenish colour, showing that the inflammation 
is terminating in resolution. The difference in the sputa, at the dif- 
ferent periods of bronchitis, was observed by the earliest writers in 
medicine, the glairy mucus first excreted having been by them deno- 
minated crude, and that in latter stages, ripe, or concocted ; indeed, 
before the introduction of auscultation, the character of the expec- 
toration afforded one of the most important signs, not only of the 
progress of the inflammation but also of the seat of the disease itself. 

It may and often does happen, that after the sputa have passed 
into the concocted form, there is a recurrence of the crude, which 
indicates that there has been also a recurrence of the active inflam- 
mation ; the appearance of the expectoration thus furnishing an 
important guide to our treatment. It may happen, too, that there is 
a partial recurrence or extension of the inflammation in one part, 
whilst the resolution is proceeding in others, in which case there will 
be a mixture of the two kinds of sputa, the opaque mucus generally 
floating in the thinner and more transparent fluid. "When, however, 
there is no relapse of this kind, the fever subsides upon appearance 
of the concocted sputa, the tongue becomes cleaner from the edges 
towards the centre, the expectoration is looser, as it is commonly 
termed, that is to say, the sputa are excreted with less difficulty, the 
respiration becomes more tranquil, and the pulse returns to its natural 
standard. 

Such is the progress of bronchitis when it terminates favourably ; 
but as this is a disease not always unattended with danger, it is very 
important to have right notions of the modes in which it may prove 
fatal, in order that we may be enabled to counteract the fatal tend- 
ency, in each particular case. Now, in all inflammations we may have 
— 1, Death from the direct effect of the inflammation, the excitement 
terminating in exhaustion or failure of the moving powers of the 
circulation, ending in death by syncope, or death from the heart ; or 
we may have death from exhaustion produced by the excessive secre- 
tion, puriform or otherwise, consequent upon the inflammation. The 
former of these is in bronchitis a possible rather than a probable 
occurrence ; the second occurs more commonly when the disease has 
degenerated into a chronic form, and seldom occurs except in those 
who have suffered from previous attacks of the acute. 2. Inflamma- 
tion of a part, the performance of whose functions are necessary to 
life, may prove fatal by its arresting the functions of that part, either 
directly or by means of the products of the inflammation. This is 
the most common mode in which bronchitis destroys life, leading to 
death by apnoea. 



MODES OF FATAL TERMINATION. 173 

It sometimes occurs where the inflammation is very intense and 
very extensive, that the swelling of the bronchial membrane which 
occurs at its commencement, is sufficient to arrest the access of air 
to the minute vessels ramifying in the cells of the lungs, and thus 
speedily cause death by apncea, before any secretion has been poured 
out into the tubes. Instances of this are not common, and when 
they do occur it is most often in those who have suffered! from re- 
peated previous attacks, and in whom the bronchial membrane is 
consequently not in a healthy state, and who are never perfectly free 
from dyspnoea, or in those whose lungs are studded with miliary 
tubercles, and in whom a severe and extensive bronchitis has been 
suddenly set up by exposure to some of its exciting causes. Where 
this has been the case, the dyspnoea becomes rapidly more and more 
urgent, tongue, lips, countenance and hands, especially under the 
nails, livid, the patient restless, anxious, and gasping for breath, the 
pulse very feeble, though the heart's action may be strong and heav- 
ing — all which circumstances show great obstruction to the transit of 
blood through the lungs ; wandering delirium often supervenes, from 
the carbonized blood circulating through the brain, and the patient 
dies suffocated, the right side of heart, lungs, liver, and venous 
system generally, being gorged with blood. These cases, I repeat, 
are not very common, but they do happen, and it is necessary to be 
acquainted with them, and to understand them, as they present one 
illustration of death from apnoea, or death from the lungs. 

The most common mode, however, of the fatal termination of 
bronchitis, is by obstruction to the respiration, and consequent death 
from apncea, caused by the inflammatory effusion in the tubes pre- 
venting the access of air to the pulmonary cells. This may take 
place at any period of the disease, and arises either from the intensity 
of the inflammation and its rapid extension to the minuter tubes, 
causing a profuse secretion to be poured into them more quickly than 
it can be excreted ; or from inability of excretion, arising partly from 
its quantity and partly from the failure of the powers of life ; in which 
latter case the cause of death is more complex, as the fatal result is 
brought about partly by failure of the moving powers of the blood, 
and partly by apncea. 

When there is danger of the disease terminating fatally by exces- 
sive secretion in its earlier stage, the dyspnoea, the lividity, and in 
fact the general symptoms presented by the patient, are the same as 
in the case of threatened apnoea from turgescence of the lining mem- 
brane of the tubes, with the exception perhaps that in the latter there 
is more heat and less moisture of the skin ; the true distinctive cha- 
racters, however, are to be found in the signs furnished by ausculta- 
tion. In the dry condition of the membrane there is, as we have 
seen, sibilus, but no rattle ; in the present instance, on the contrary, 
there are rattles to be heard over the whole surface of the chest, and 
the more extensive these are, and "the smaller 1 ' they appear, the 
greater is the danger. 

It is, however, in the latter stage of the disease, where the powers 
of the constitution are naturally feeble, or where they have been 



174 BRONCHITIS — PROGNOSIS. 

exhausted by former diseases, especially by previous attacks of bron- 
chitis, or by injudicious treatment at the commencement, that the 
greatest number of cases prove fatal, and that from the combined 
agency of exhaustion and excessive secretion ; constituting the suffo- 
cative catarrh of the French authors, more properly termed suffoca- 
tive bronchitis. The tendency to this mode of fatal termination, is a 
circumstance which it is extremely important to keep constantly in 
view in severe cases of bronchitis. The signs which threaten this 
result are, increase of the dyspnoea, generally with a concomitant 
increase of the lividity ; a failure of the circulation evinced by the 
pulse becoming very soft, irregular, and sometimes intermittent ; 
coldness of the extremities, with delirium or stupor. Auscultation 
discovers large and small rattles over the whole of the chest, with 
more or less wheezing, the resonance of the chest, upon percussion, 
remaining unaltered. Such is the ordinary progress of acute bron- 
chitis, either to recovery or a fatal termination ; it very frequently, 
however, runs on to the chronic form, which requires a separate 
notice. 

The diagnosis of bronchitis, which is a matter of some practical 
importance, has become comparatively easy, since the general adop- 
tion of auscultation. From inflammation of the substance of the 
lung it may be distinguished by the moist rattles which we have 
already described; by the resonance upon percussion remaining unal- 
tered, and by the absence of those auscultatory signs which will be 
presently pointed out as indicative of pneumonia ; by the expectora- 
tion being more decidedly mucous, and not tinged by blood inti- 
mately mixed with it, as in the latter disease ; and by the general 
symptoms of a less heat of skin and a softer pulse. From pleurisy it 
may also be distinguished, by the absence of the stitch, and the dif- 
ference between the stethoscopic sounds. It is true, indeed, that we 
may have either of these last-named diseases concurring with bron- 
chitis ; in which case they may be distinguished by their character- 
istic symptoms, a diagnosis which certainly requires some tact and 
experience in auscultation ; though it may be observed, that there is 
not often much danger of overlooking the bronchitis under such 
circumstances, since its peculiar sounds are more likely to mask, than 
to be masked, by those of the other diseases. Perhaps the most diffi- 
cult point in the diagnosis of bronchitis is the distinction between 
the primary idiopathic form of the disease, and that which occurs as 
a complication or concomitant of continued fever ; it is, however, a 
difficulty that may readily be avoided by those who are familiar with 
the latter disease, and the error is perhaps to be the most carefully 
shunned, by those who are prone to rely too exclusively upon the 
local signs furnished by auscultation. There is, again, often a diffi- 
culty as to bronchitis and phthisis, but this, also, is a question belong- 
ing rather to the diagnosis of the latter disease, and the same may 
be said of its concurrence with diseases of the heart or large vessels. 
The truth is, that though bronchitis occurs as a primary disease, and 
a formidable one too ; it often is also a symptom only, or a conse- 
quence, of some other lesion ; so that the presence of its local signs, 



DIAGNOSIS. 175 

particularly when unattended with the fever that belongs to it, in its 
acute form, ought never to satisfy us that we have ascertained the 
whole extent of the disorder. 

The causes of bronchitis, like those of most other diseases, have 
been divided into predisposing and exciting; in the more correct 
language which we propose to adopt, they may be classed as — 1, 
conditions which induce a susceptibility to the disease, or an inability 
to withstand its direct causes: and 2, the direct causes themselves. 

Now as to the predisposing conditions: there is no age which is 
exempt from its attacks, although the very old and the very young 
suffer the most severely from it ; it affects alike, coeteris paribus, males 
and females. As regards habits of life, those are the least liable to 
its attacks who live temperately, and expose themselves moderately 
and cautiously to the tonic effects of cold ; whilst, on the other hand, 
those who are enervated either by intemperance or other excesses, 
or who live in confined dwellings, or pass their time in overheated 
rooms, or inhale the carbonised air of crowded assemblies, or are 
employed in heated work-rooms, where the atmosphere is often 
vitiated, are most liable. Amongst the predisposing conditions too 
must be reckoned, previous attacks of the disease, and also diseases 
of the kidneys and the heart, if, indeed, the two latter are not to be 
reckoned amongst the direct causes. 

The direct cause of bronchitis is commonly exposure to cold, or 
still more to cold and damp combined ; especially after having been 
subjected to the influence of those conditions which have been 
pointed out as weakening the power of resisting the impression of 
such agencies. In infants, the disease is often excited by the process 
of dentition. The inhalation of irritating gases or of minute par- 
ticles of dust, sand, or filings suspended in the air, also produces the 
disease amongst the different classes of artisans who are exposed to 
them in their respective operations. As has been already observed, 
bronchitis accompanies several other diseases, as measles, continued 
fever, phthisis, pneumonia, disease of the heart and of the kidneys, 
&c, either as a consequence, an accidental complication, or a cause. 
It is also a very frequent accompaniment of that extensive epidemic 
the influenza, so much so, that many, or rather most, authors have 
regarded that disease as an epidemic bronchitis; the experience, 
however, of late years, has taught us that bronchitis is not essential 
to influenza. 

Notwithstanding the apparently trivial nature of bronchitis in 
many instances, it is, nevertheless, one of the most fatal, as well as 
most frequent diseases in this, and perhaps in all variable climates. 
Our prognosis, therefore, ought to be very guarded in all severe 
cases, and in many it must be exceedingly doubtful, if not unfavour- 
able. The circumstances which influence the amount of danger, are 
the age and constitution of the patient — the attack being a first one, 
or a repetition of a disease from which the patient has frequently 
suffered before — the extent and severity of the attack — the season of 
the year and perhaps also the locality. 

When the disease attacks infants and young children, it is fre- 



176 ACUTE BEONCHITIS. 

quently very little amenable to remedies, and is fatal in great num- 
bers of instances, more so than is perhaps commonly believed ; since 
by far too many of such, cases are set down as inflammation of the 
lungs, or pneumonia. In old people, again, there is a great suscepti- 
bility of the disease, which though inflammatory in the first instance, 
is very little amenable to such means as it would be safe to employ, 
and in the more advanced stage, there is a tendency to sinking, the 
danger of which is aggravated by the debility of age. Independently, 
however, of the age of the patient, the cachectic state of body induced 
by intemperance, or organic disease of any kind, greatly lessens the 
probability of recovery. This is especially applicable to disease of 
the heart and kidneys, the former of which, by impeding the return 
of the blood from the lungs, is an additional cause of that obstruction 
to the pulmonic circulation which is so dangerous in bronchitis ; and 
disease of the latter organs, which is at all times apt to induce rapid 
effusion into the areolar tissue, is still more apt to do so in any part 
which is the seat of inflammation, and consequently when bronchitis 
attacks such subjects there is danger of a sudden and rapid anasarca 
of the submucous areolar tissue, threatening death from apnoea. Of 
all previous diseases, however, that which most increases the risk of 
an unfavourable termination, is a succession of previous attacks of 
the same disease, or a pre-existing chronic bronchitis, especially if it 
have been of long duration. Bronchitis is also more dangerous in 
the winter and spring than at other seasons of the year, especially if 
there have been cold and damp weather. 

Independently, however, of all these considerations, a severe 
attack of bronchitis, affecting extensively the minuter tubes, (the 
capillary bronchitis of some authors,) is at all times to be dreaded. 
When, with much febrile excitement, rapid, hurried, and distressed 
breathing, and quick and sharp pulse, there are small sibilant sounds, 
or small rattles, over the whole of the chest, there is always reason 
for apprehension, which is increased by lividity of the lips or fingers. 
When, however, although the case be severe, the expectoration 
becomes more free and is performed without pain, and the sputa 
gradually change from the crude and transparent to the bland, 
opaque, and whitish or greenish; there is reason to hope that resolu- 
tion is taking place; and still more, if at the same the tongue begins 
to clean from the edges towards the centre, and the pulse and respi- 
ration becomes less hurried. On the other hand, a recurrence of the 
transparent sputa is a sign of a fresh attack, or extension of the 
inflammation, and is of course, as far as it goes, an unfavourable sign. 
The sudden suppression of the expectoration, again, especially if it 
be attended by increased dyspnoea, or lividity, or low delirium, por- 
tends the most urgent danger. Delirium is in itself at all times a 
dangerous symptom, especially in old persons and in those who have 
been previously subject to the same disease. 

There are few diseases in which the pulse requires more careful 
watching than in bronchitis. It is from the commencement generally 
more compressible than in inflammation either of the lungs or pleura, 
but when the dyspnoea becomes urgent, and there is much lividity, 



TREATMENT. 177 

it often becomes exceedingly small, although the impulse of the 
heart may remain powerful ; this indicates great obstruction to the 
passage of the blood from the right to the left side of the heart, and, 
therefore, urgent danger: sometimes, too, under these circumstances, 
it becomes intermittent, though at others, owing to the difficulty of 
propelling the carbonized blood through the extreme circulation, the 
pulse is throbbing and even large, with a feeling as if of a back stroke. 
A very scanty secretion of urine is also, if it continue obstinately, 
and independently of profuse perspiration, an unfavourable symptom, 
as it shows sufficient obstruction to the pulmonic circulation to cause 
engorgement of the liver, and thus, upon principles already explained 
(p. 35), to diminish the secretion from the kidneys. 

From what has been said of the nature and danger of bronchitis, it 
will be at once apparent that the indications are seemingly opposite 
and inconsistent, but to an experienced and rational practitioner by 
no means incompatible: they are — to subdue inflammatory action, 
without exhausting the patient's strength — to facilitate expectoration 
without stimulating the bronchial membrane — to allay irritation, 
without oppressing the brain by anodynes — and subsequently to sup- 
port the strength of the patient, without rekindling the inflammation ; 
to which may be added, the relieving the lungs by keeping up a free 
action of the other excreting organs. 

The first and most obvious means of reducing the inflammatory 
action is the abstraction of blood, but in the use of this we must be 
restrained by the risk of exhausting the strength of the patient, and 
therefore it must be practised with the greatest caution. In young 
and strong subjects, in the country, blood may often be drawn with 
advantage in the commencement of the disease, particularly before 
the dry sibilus has been superseded by the moist rattle ; but as a 
general rule, in large towns and in elderly persons, or those of infirm 
constitutions, general bleeding ought not to be attempted. When, 
however, the above conditions being in its favour — the pulse having 
some degree of firmness, the skin being dry and hot, the dry sibilus 
not having yet given place to the moist rattle, or the secretion, if 
any, being still of the glairy transparent character — there is much 
febrile action and dyspnoea, with evidence upon auscultation of the 
smaller tubes being involved to a greater extent, and the urgency of 
the case is such as to render it important to make a speedy impres- 
sion upon the system, venesection may be performed. For this pur- 
pose the patient may be raised into a sitting posture, and the blood 
allowed to flow from a pretty large orifice until signs of fainting 
show themselves ; provided, as a general rule, that not more than a 
pint be taken. The blood when drawn under these circumstances 
will be buffed and somewhat cupped. 

In most cases, however, it will be more prudent to have recourse 
to local, in preference to general, bleeding, and in adults, the best 
mode is by cupping, which has the double advantage of reducing the 
vascular excitement, and acting as a revulsive; in nervous females 
and children, when depletion is necessary, leeches may be employed. 
It is not, however, to be supposed, that in all cases, even of eonsider- 

12 



178 ACUTE BRONCHITIS. 

able severity, depletion in any form is necessary ; and in large towns, 
where the loss of blood is so generally, though not perhaps imme- 
diately, followed by exhaustion, we should not practise it, unless the 
indications in its favour are decided. 

Emetics at the commencement of an attack of bronchitis often 
prove of excellent service : as already explained, they have a tendency 
to relieve that state of active congestion of the vessels of the mucous 
membranes which exists in a marked degree in the first stage of this 
disease ; they should therefore be exhibited before the moist sounds 
begin to prevail : they are especially useful in the bronchitis of in- 
fants. The best form for administering them is, for adults, the com- 
bination of antimony and ipecacuanha (F. 16, p. 140), and for infants 
and young children the safest is the ipecacuanha alone, a few grains 
of which may be given in some watery vehicle. 

The next remedies which require consideration, with a view to 
subduing inflammatory action, are antimony and mercury. The 
former of these, where it is not contraindicated by irritability of the 
stomach or bowels, is a remedy of which we have already spoken as 
exerting a special power over inflammations of mucous membranes, 
and is on this account particularly applicable in bronchitis ; indeed, in 
the generality of cases of simple acute bronchitis it may form the staple 
of our treatment. Mercury has been much recommended by several 
writers of high authority; and as an adjuvant to other remedies, and 
in cases of great severity, in which it is necessary to use every means 
of subduing the inflammation, it may be used with some freedom ; 
but as a general rule it ought only to be a secondary remedy, and 
we must not rely for fulfilling the primary indication upon the in- 
ducing of ptyalism ; since, in cases of capillary bronchitis, which are 
the most urgent and dangerous, we can never feel confident that the 
disease has not a tuberculous origin, and in such cases, the use of 
mercury, in any considerable quantity, would tend to aggravate the 
mischief. The best practice will in general be found to be, to give 
the antimony in solution combined with an anodyne and diaphoretic 
(as in the mixture F. 17, p. 140); the antimony may, however, be 
increased or diminished according to the circumstances of the case. 
In general the first dose of the antimony may be about half a drachm 
of the wine of the potassio-tartrate, or one-eighth of a grain of the 
salt itself, to be repeated every four hours in solution : this may be 
gradually raised when necessary to half a grain of the latter, or two 
drachms of the former, beyond which it will seldom be necessary to 
increase the dose ; where it is thought expedient, however, to push 
the drug still further, it may be well to lessen the intervals between 
its being taken, as from four to three hours. It must, however, be 
regulated by its effects upon the disease and upon the system ge- 
nerally, rather than by weight and measure. The dose should be 
increased to such an extent as to keep up a slight nausea, and so 
maintained till the skin is moist and cool, and the pulse soft and less 
frequent. In conjunction, or in combination, with the antimony, 
mercury in some form may be given in moderate doses ; in the more 
severe cases the combination of calomel, antimony, and opium (F. 3, 



TREATMENT. 179 

p. 102), may be given two or three times a-day, the mixture being 
continued at the same time. In general, however, and particularly 
where the pulse is small as well as quick, a combination of Dover's 
powder and the mercury with chalk is to be preferred. (22)* 

When the skin is less dry and hot, and there are moist rattles of 
various sizes to be heard over the surface of the chest, the antimony 
may be diminished or discontinued, and ipecacuanha employed as 
the safest and least irritating of expectorants. For this purpose ipe- 
cacuanha wine may be added to the mixture instead of the anti- 
monial, and at the same time about five grains of Pil. Conii co. of the 
Pharmacopoeia administered two or three times a day, or the mixture 
(23)f may be employed, and the pill of Dover's powder and mercury 
with chalk exhibited night and morning. Another admirable ex- 
pectorant is the inhalation of the steam of warm water. 

This is the period of bronchitis at which counter-irritation may be 
most advantageously employed, or at least commenced ; as before the 
skin has become soft and moist, and the pulse less sharp, it only ag- 
gravates the disease, as has been already explained in speaking of the 
treatment of inflammation in general (p. 105). It is, however, neces- 
sary here to inisist again upon this point of practice, there being no 
disease in which blisters are so much abused as in bronchitis, and 
there is no popular error ,more pernicious than the very prevalent 
one that in a " cold upon the chest" a blister is a very safe remedy. 
The best mode of counter-irritation is generally the common blister, 
which may be applied over the chest, and allowed to remain on from 
twelve to sixteen hours or more in the case of adults ; in children 
under a year old a good plan is to apply the blister for an hour, and 
then remove it for an hour, and if there be no vesication at the end 
of the second hour, to replace it; for the inflammation of the skin 
having been excited, it will very often go on to vesication, that is, 
effusion of serum, after the irritating cause has been withdrawn; 
when there is urgent dyspnoea, and we are anxious to produce coun- 
ter-irritation as speedily as possible, a mustard-poultice to the chest 
or between the shoulders is to be preferred to a blister, or the acetum 
lyttae may be painted on the chest. 

It commonly happens in a sound subject, not too much advanced 
in life, that bronchitis thus treated terminates favourably, and little 
further treatment is required beyond, perhaps, the application of an 
additional blister, and the continuous use of the anodyne and ex- 

* (22) Jc. Pulv. Ipecac, co. gr. vi. — x. 
Hydr. cum Cret. gr. iij. — vi. 
Mucilag. quant, suf. 
Ft. Pil. ij. vel iv. ; of which one or two are to be taken twice a-day. 

f (23) R.Ext. Conii, gr. xv.-xx. 
Ext. Glycyrrbiz. gr. xxiv. 
Soda3 Sesquicarb. ►) j« 
Sp. Pimentre, g i. 
Vin. Ipecac, n^ xl. — £ j. 
Sp. iEth. nit. 3 i. — ^ij. 
Aq. distillat. q. s. 
To make a 3 iv. mixture, of which the one-fourth is to be taken every sixth hour. 



180 ACUTE BRONCHITIS. 

pectorant draught, the vessels of the mucous lining of the bronchi 
returning to their natural condition without any tonic or stimulating 
measures beyond a gradual return to the patient's usual diet. It may 
occur, however, either from neglect at the commencement of this dis- 
ease, or from the loss of contractility in the capillaries, arising from 
previous attacks of inflammation, or from visceral disease, or a con- 
stitution impaired by time or excesses, that although there may be 
no very alarming symptoms, yet there appears to be little attempt at 
a return to the natural condition of the membrane, as shown by the 
continuance of the dyspnoea, the wheezing, or the moist rattles, just 
as we often see the vessels of the conjunctiva remain injected after 
inflammation of that membrane ; in this state of things some rather 
more stimulating expectorants will be of service. If the pulse be 
soft, the tongue moist, and the skin perspirable, and there are mucous 
rattles in the chest, but no great amount of expectoration, the am- 
moniacum may be given with advantage, in combination with about 
twenty minims of tincture, or about a drachm of the oxymel of 
squills, with the addition, where the urine is scanty, of about half a 
drachm, of sp. 2eth. nit.; and a repetition of the blister will, at the 
same time, be advisable. When there appears to be little secretion 
from the tubes, as shown by the diminished rattles but increased 
sibilus, especially if the urine be loaded or high coloured, and the 
dejections deficient in bile, the pill (24)* may be used. It may hap- 
pen, however, that as the activity of the inflammation subsides, a still 
more alarming condition ensues, the patient becoming nearly pros- 
trate, the pulse feeble, and the signs of sinking already described 
presenting themselves. In this state, stimulating expectorants, as 
well as general stimulants, must be freely administered. The best 
medicine under these circumstances is the combination of ether, am- 
monia, and senega (25)f ; but a most important adjunct, if not the 
most essential part of the treatment is the liberal but regulated use 
of wine or brandy ; the former is generally to be preferred, and, in 
those who have been accustomed to its use, should be allowed to the 
extent of about four ounces a-day, as soon as the signs of exhaustion 
begin to show themselves, and it may be gradually increased to eight, 
twelve, or more according to the condition of the patient. When 
these measures become necessary, the situation of the patient is in 
the highest degree perilous, and the prognosis very unfavourable ; 
still, by their persevering application many such cases may be saved. 

* (24) R. Pil. Hydr. 
Pulv. Ipecac. 
Pulv. Scillse, aa gr. i. 
Ext. Conii, gr. ij. 
Ft. Pil. ; to be repeated three times a-day. 

j- (25) R. Ammon. Sesquicarb. gr. v. 
Sp. Mth. co. 
Tinct. Scillae, 
Tinct. Hyoscy. aa rr^ xx. 
Decoct, Senegse £ i. Misce. 
Ft. Haust. ; to be repeated every fourth hour. 
About two or three drachms of the Liq. Ammon. Acet. may be added when the skin 
is dry. 



CHRONIC BRONCHITIS. 181 

The difficult question to decide at this stage of the disease is 
'he expediency of an opiate : the restlessness, which arises in great 
measure from the incessant cough, is often most distressing, and 
tends greatly to wear out the strength of the patient; to procure 
sleep, then, is highly desirable ; but on the other hand, we know that 
there is generally imperfect decarbonization of the blood, and, there- 
fore, with one narcotic poison in the system, we must be cautious 
about introducing another. The suppression of the expectoration, 
too, if it take place very suddenly or completely, is also attended 
with danger, and often has a tendency to increase the oppression of 
the brain: great care is, therefore, to be used in the exhibition of 
opium in bronchitis attended with much dyspnoea, and as a general 
rule, it ought never to be used when the countenance is dusky or the 
lips livid; but when the cheeks remain florid and there is a free 
expectoration, an opiate, given at bed time in combination with an 
expectorant, often acts almost magically (26*). The treatment of 
bronchitis has been described at some length, not that it is possible, 
by the most detailed plan, to include that which shall be applicable 
to every particular case of this varying disease, but because it is of 
the greatest importance to understand the different indications, and 
the principles upon which they are to be fulfilled, for the very fre- 
quency of the disease is too apt to induce a routine of practice, and 
therefore one in which little regard is paid to the distinction between 
the different phases, which require such different and even opposite 
remedies. 

It has already been remarked, that after an attack of acute bron- 
chitis there may be little or no attempt at a return in the bronchial 
membrane to its natural condition, its vessels remaining injected, 
apparently from a want of contractility, the part being, in fact, in a 
state of asthenic hyperasmia, or passive congestion, the blood circu- 
lating very slowly in the capillaries. 

The immediate effects of this condition of the bronchial membrane 
will be turgescence, probably oedema of the submucous areolar tissue, 
and altered secretion, the latter being generally increased, the neces- 
sary symptoms of which will be dyspnoea, cough, and sometimes 
expectoration. This state of things may, however, come on to all 
appearance spontaneously, and without any previous acute disease ; 
in either case it is termed chronic bronchitis. 

The above constitute what may be termed the essential and neces- 
sary conditions of chronic bronchitis, but others are often superadded 
to them, or rather follow as their consequences, which are the causes 
of the distress and danger often attendant upon the disease. 

The continued hyperaemia of the mucous membrane may lead to 
permanent thickening from the effusion of fibrinous matter into the 

* (26) R. Opii, gr. i. 

Antim. Pot. tart. gr. \. 

Confect. Ros. q. s. Ft. Pil. ; to be taken at bed time. 

Or, R. Morpkice Hydrocblor. gr. £. 
Pil Scilloe co. gr. iv. 
Ft. Pil. ; to be taken at bed time. 



182 ITS PATHOLOGY. 

areolar tissue; this will at once impede the respiration, and interfere 
with the aeration of the blood ; hence there may arise increased dysp- 
noea, wheezing, and lividity: or, again, the puriform secretion from 
the mucous surface may be so excessive as not only to give rise to 
cough and dyspnoea, but also, by the continual drain upon the sys- 
tem, to lead to pallor, hectic, and emaciation. 

We perceive from this, that when the above structural changes 
have supervened upon chronic bronchitis — and they are such as that 
disease is continually tending to induce — the affection assumes a 
highly dangerous character, and a fatal termination may be appre- 
hended in one of two modes. 

1. Where there is dyspnoea and wheezing, from the walls of the 
tubes being thickened, and their calibre thereby diminished, the ten- 
dency is to death by apnoea. 

2. When, on the other hand, there is excessive puriform secretion, 
death from gradual sinking — death, that is to say, from asthenia, is 
to be dreaded. 

The cases of these two different classes, though consequences of the 
same disease, present remarkable contrasts ; in the former, where there 
is obstruction to the functions of the bronchial tubes by change in 
their structure, the chief ausculatory sign is wheezing; in the latter, 
where the chief mischief is the great muco-puriform secretion, there 
are rattles : in the former there is great lividity, the countenance will 
be often dusky, and the lips and ends of the fingers blue ; in the latter 
there is indeed a slight livor of the lips, though it requires a practised 
eye to recognise it, but otherwise there is pallor: in the former there 
is a bloated countenance, and sometimes general oedema ; in the latter 
there is emaciation. In the former the patient dies suffocated ; in the 
latter exhausted. 

These are the two simple forms of chronic bronchitis, though 
neither is often presented to our notice uncomplicated by the other, 
and it is perhaps from their joint effect that another change takes 
place in the bronchial tubes, of great importance in connection with 
the subject of chronic bronchitis. It appears to be a law in pathology, 
that when a membrane overlaying muscular fibre is inflamed, the lat- 
ter loses in some measure its contractility ; and the proposition may 
perhaps be extended to include fibrous tissues generally : if the in- 
flamed membrane be a mucous one, the contractility of the muscular 
fibre is at first increased, and subsequently diminished ; as we see 
in the diarrhoea and subsequent constipation which occurs in inflam- 
mation of the mucous membrane of the intestines. Now, according 
to this, not only should we expect some increase in the action of the 
non-striated muscular fibres of the bronchial tubes, which it is by no 
means improbable does actually take place, aggravating the dyspnoea, 
and aiding the swelling of the membrane in producing the sibilus; 
but also that there would subsequently be a diminished power of 
expelling any accumulated secretion, and also a tendency to dilate, or 
become enlarged, under the slightest increased distending force ; such 
a force is often supplied by this very secretion, as well as, in the 
opinion of some, by the convulsive efforts of coughing. Accordingly, 



CHROXIC BRONCHITIS. 18 



r > 



we do find every variety of dilatation of the bronchial tubes ; some- 
times a single pouch like an aneurism in an artery; sometimes a 
series of dilatations in the same tube; sometimes a cylindrical dilata- 
tion affecting a congeries of tubes, branches of an entire bronchi;: 1 
tree. The section of a cluster of tubes of this kind may be compared 
to the fingers of a glove.* 

Before quitting this subject, we would remark, that though we 
have sometimes the accumulated secretion as the cause of this dilata- 
tion, and the changed condition of the walls of the bronchial tube as 
the reason of their susceptibility of the change, we would not limit 
the mechanical cause to the former ; indeed, it is not improbable that 
where the contractility of the walls has been destroyed by inflamma- 
tion, the atmospheric pressure in inspiration will be a sufficient cause ; 
and besides this, as we shall hereafter see, the instances of greatest 
dilatation do* not generally occur in cases of simple bronchitis, but in 
those which are complicated with pneumonia, or pleurisy, or both, 
where the subsequent changes in the surrounding textures have often 
a considerable influence in promoting the dilatation of the tubes. 

When dilated tubes are added to the other changes produced by 
chronic bronchitis, there will of course be considerable aggravation 
of the dyspnoea, and the lividity consequent upon the obstructed 
function of the lun^s. If the dilatation is in the small tubes there 
will be sibilus and wheezing, with deficiency of respiratory murmur ; 
the presence or absence of rattles depending upon the amount of 
secretion; if in the larger, there will be ronchus, with or without large 
rattles. It may be remarked, however, that there seems to be scarcely 
any limit to which the tubes, especially those of the third or fourth 
dimensions, may dilate ; so that they often present the physical signs 
of cavities produced in the lungs in other ways. 

The expectoration in chronic bronchitis may, as we have observed, 
be very scanty, and sometimes transparent: often it is abundant, and 
of a muco-puriform character ; but where there is the latter associated 
with dilatation of the tubes, the puriform mucus from remaining in 
these pouches, is coughed up in roundish lumps, looking, when seen 
floating in a fluid, like coins, and thence called nummular sputa. 

We have already pointed out the different modes of fatal termina- 
tion in chronic bronchitis, and the different symptoms which charac- 
terise the tendency to one or the other ; still, the two forms of the 
disease may exist in the same subject, and in the worst cases they 
commonly do so. In such there will be wheezing, ronchus, and rat- 
tles ; there will be lividity of the tongue, lips, and fingers, with pallor 
of the surface generally ; there will be emaciation, but with a bloated, 
and often cedematous condition of the face and extremities; in the so 
cases, too, we often have the hands emaciated, but the tips of the 
fingers swollen from the long continuance of venous congestion, and 
the nails livid and curved; there is orthopncea; the skin is sometimes 
dry and harsh, at others, especially over the extremities, bedewed 

* See a good representation in Drs. Handfield Jones and Sieveking's Pathological 
Anatomy, Philadelphia ed. p 389. 



184 PROGNOSIS. 

with a clammy perspiration. The signs of obstructed pulmonic cir- 
culation being added to those of exhaustion from excessive secretion, 
we have palpitations from dilated right ventricle, defective secretion 
of bile from gorged liver ; and scanty urine. 

It must be apparent from what has been said, that chronic bron- 
chitis is a disease continually tending to a fatal termination, and that 
even when it is present in its simplest and mildest form, there is 
danger of those additional lesions which bring about this result. 
Whilst there are dyspnoea, cough, and expectoration, there is occa- 
sion for the greatest caution. When there are orthopnoea, wheezing, 
and lividity, puriform expectoration, hectic, and emaciation, there 
are grounds for the most serious apprehensions. 

The urgency of the disease is liable to great variations; many 
persons are affected by it only in the winter, and are nearly if not 
entirely free from it in the summer months ; this form of complaint 
being popularly known as winter cough; but after some years it 
generally happens that the disease does not altogether cease, but 
merely becomes less severe in summer, whilst the winter attacks 
become longer and more violent. The persistence of the symptoms 
during the summer is a sign that structural changes are going on, or, 
in other words, that the disease is proceeding, though it may be but 
slowly, to a fatal termination. 

The treatment of chronic bronchitis must be partly preventive, 
and partly directed to meet the more urgent symptoms as they arise. 
When a person has been the subject of a winter cough, the great 
object should be, if possible, to take advantage of the summer inter- 
mission, or even remission, if it be no more, to correct the morbid 
habit or tendency, so to speak, of the bronchial membrane. Now as 
this appears to consist mainly in a state of passive congestion of that 
membrane, (p. 29), to which there is often added deficient tonicity of 
the tubes, the best means for correcting it will be a moderately tonic 
regimen, and mode of living. Of these a pure and moderately 
bracing atmosphere, is a most essential part. Generally the sea will 
be found to agree well with such patients during the summer ; and 
that often in situations where it might be supposed to be too keen, 
as on the eastern coast, for instance, at Margate or Eamsgate, or even 
at Lowestoft or Cromer. It is generally, however, for those in whom 
there is considerable expectoration that such situations will be found 
best suited; for those in whom there is wheezing, with little or no 
expectoration, the rather more relaxing atmosphere of the coasts of 
Devonshire and Cornwall is to be preferred. If the patient be ordi- 
narily resident in a large town, he will often derive much benefit 
from a pure and moderately bracing inland air. The diet should be 
nutritious; about two glasses of port wine, if it agree with the 
patient's stomach, should be recommended where there is much 
secretion. At this period too tonic medicines may be of service ; in 
cases of profuse expectoration the sulphate of iron is often very use- 
ful. What perhaps is a still better remedy is the sulphate of zinc, 
which will be at once a moderate astringent and a tonic. This, with 
a little conium, will be very applicable to the more common class of 



TREATMENT OF CHRONIC BRONCHITIS. 185 

cases, in which though there is some cough and expectoration, the 
latter is not excessive (27).* When slight attacks of an acute or 
sub-acute character supervene during the summer thej must be 
treated as ordinary bronchitis. In those in whom the disease has 
not been confirmed, the attempt may be made during the summer to 
inure the patient to the use of cold, in the form of bath sponging or 
effusion, as recommended against catarrh. 

Having taken precautions in the summer to brace the patient 
against the attacks which are to be expected in the winter, equal pre- 
caution must be used to mitigate the attack when the first symptoms 
begin to show themselves. This, however, is not to be done by too 
soon confining the patient to the house, as in general he should be 
encouraged to go out in fine weather to the last, carefully avoiding 
night or evening air. The clothing should be uniformly warm; 
light woollen being worn next the skin, but heavy clothing avoided. 

In severe and threatening cases the patient should be confined to 
the house in the winter, and if there be much cough, and it appear 
easily excited by the admission of cool air, he should even be kept 
in apartments of which the temperature should not be allowed to fall 
below 60°; and when, as they often will do, acute attacks supervene, 
they must be treated upon the principles already recommended for 
acute bronchitis, it being always borne in mind that in such cases 
there is an earlier tendency to sinking, and therefore that support 
and even stimulants must not be long withheld. 

* (27) R. Zinci Sulphat. gr j. 
Ext. Conii, gr. iv. 
Ft. Pil; to be repeated twice or thrice a- day. 



186 PNEUMONIA — PLEURITIS. 



XII. 
PNEUMONIA— PLEUEITIS. 

Pneumonia may be defined to be inflammation of the air-cells of 
the lungs, though this inflammation may give rise to different products, 
and consequently different results. It sometimes happens, indeed, 
that inflammation of the bronchial membrane extends to the air- 
cells, and so involves the substance of the lung, and more commonly 
the disease of the air-cells implicates the bronchial tubes; still we 
have many instances of its commencing in the former, and confining 
itself solely to them; and therefore it is desirable to consider it 
singly. 

There has been a good deal of difference of opinion as to the exact 
seat of the inflammation — as to whether, in fact, it is in the wall of 
the cell comprising the vessels, or whether it is in the mere lining 
or internal surface of the cell; a right application, however, of the 
laws of inflammation, in connection with the structure of the part, 
will be sufficient to show that these different views are rather partial 
and defective, than involving any real error. 

Now, we have seen that the first step in the process of inflamma- 
tion is that of engorgement or active hypersemia, and as the inter- 
stices between the cells consist almost entirely of a plexus of minute 
vessels, the result must be a swelling of the walls of the cells, with a 
diminution of their cavities, giving to the lung apparently a closer 
texture, and one more largely supplied with blood — this is what is 
termed the stage of engorgement. At this period of inflammation, 
however, the true inflammatory products have hardly made their 
appearance, and we have - merely the tumescence resulting from the 
increased supply of blood. When a lung in this stage of inflamma- 
tion is examined after death, it is found not to have lost its property 
of crepitating when squeezed between the fingers, although it does 
not collapse so readily under the pressure of the atmosphere as 
healthy lung; it is of a florid red colour, and the blood flows freely 
from it when it is cut into. 

The next step in the process, if the inflammation do not subside 
by resolution, is the effusion of some of its characteristic products. 
Now, although in the case of the disease under consideration these 
products vary in their subsequent results, they in the first instance 
occur in the form of lymph, either fibrinous or corpuscular, or in the 
compound form in which the fibrine and corpuscles are mixed (pp. 
50, et seq.), the former, or the latter preponderating, according to the 
greater or less constitutional power of the patient. 

When there is active inflammation in a subject of tolerably good 
power, we have the greatest proportion of fibrine, which almost 
immediately assumes the solid form, giving rise to consolidation of 
the lung, which, owing to the large supply of blood, retains the red 



PATHOLOGY OF PNEUMONIA. 187 

colour which it had acquired in the first stage of the inflammation. 
The highly-vascular inflamed lung, thus consolidated, resembles the 
liver in appearance, and is said to be " hepatized ;" and its condition 
in this stage of the inflammation is called red hepatization. It should, 
however, here be remarked, that there is a difference of opinion 
amongst authors as to the exact situation in which this deposit takes 
place. Lsennec and others were of opinion that it took place into 
the cells, filling them up, and, as it were, obliterating them ; and 
certainly the finely granulated structure, which the lung in this stage 
of inflammation commonly exhibits, when lacerated or cut into, seems 
to favour this supposition ; and that this is really so, in some cases 
at least, of acute pneumonia, has been demonstrated by Reynaud. 
Others again, amongst whom may be mentioned Andral and Stokes, 
have maintained that the red hepatization of acute pneumonia de- 
pends not on any deposits in the vesicles, but by the walls of these 
vesicles being so thickened or swollen by the excessive congestion of 
blood in their vessels, that their surfaces are approximated, and 
sometimes so closely as to obliterate the cavities ; and they further 
account for the red hepatization presenting in some cases a granular, 
and in others a smooth surface, by supposing the latter to arise from 
the more intense congestion and perfect obliteration of the cells ; and 
it cannot be denied that the inference to be drawn from the examina- 
tion of dried specimens of hepatized lung is, that in some cases this 
hepatization results from congestion and probably coagulation of 
blood in the vessels. This view of the matter overlooks, however, the 
true products of inflammation, and merely shows that the condition 
termed hepatization, or one closely resembling it, may be produced 
independently of them ; it does not, however, invalidate the observa- 
tion of Reynaud, of the actual presence of the inflammatory products 
in the air-cells ; nor, on the other hand, do the latter observations 
prove that in all cases where plastic lymph is poured out, it is neces- 
sarily effused into the cells, and into the cells alone. It is not of 
great practical importance, and therefore not consistent with the 
object of the present work, to pursue this question further ; we may, 
therefore, briefly state, as the result of these seemingly opposite 
observations, that engorgement of the lung, without plastic effusion, 
may exist to such an extent as to give rise to a condition apparently 
the same as that commonly described as red hepatization ; but that 
this engorgement, if it do not terminate by resolution, is most fre- 
quently followed by the extra- vascular product of inflammation, i. e., 
the effusion of inflammatory lymph ; this taking place into the air- 
cells, and so filling them with plastic lymph, and giving the hepa- 
tized lung the granular appearance, or, according to the supposition 
of Dr. Williams, into the other tissues constituting the substance of 
the lung, when we have the smooth surface. 

Such are the steps by which the lung is brought to the state of red 
hepatization. Here, however, it may be well to remark, that instead 
of the plastic form of effusion which we have described as producing 
this state, we may have the effusion of the compound or corpuscular 
lymph, or lymph in which there is a great excess of serum, eonstitu- 



188 PATHOLOGY OF PNEUMONIA. 

ting what may be termed serous pneumonia, or inflammatory oedema 
of the lung, a condition not generally recognized by authors, but of 
the existence and danger of which there can be no doubt ; this state 
supervenes sometimes very suddenly upon the first stage of pneumo- 
nia, generally in persons of impaired constitutions and unsound vis- 
cera ; at others, indeed, the previous stage may have been so short 
as almost to have escaped detection ; it is possible, too, that the lymph 
may in some cases be reabsorbed, if the inflammation subside imme- 
diately after its effusion. 

When a portion of lung has been brought to the state of gran- 
ular hepatization, it may subsequently undergo various changes. 

(1.) Resolution and absorption of the effused lymph may take 
place, and thus the lung may be restored to the healthy state ; or — 

(2.) The lymph effused into the air-cells may take the form of pus, 
and thus the whole of the inflamed part become infiltrated with pus, 
resembling, as has been observed, a sponge soaked with that fluid, 
without any circumscribed abscess being formed ; or if the effused 
lymph have been of the corpuscular form in the first instance this 
infiltration with pus may take place without any previous consolida- 
tion. Under these circumstances sloughing of the lung may follow : 
or if this do not happen, and the patient do not sink during the pro- 
cess, the lung may be restored to its healthy condition by the lique- 
faction of the effused lymph, and its subsequent expectoration ; or — 

(3.) The portion of lung which has been condensed and hepatized 
becomes harder and dryer, with a uniformly grey colour ; and if the 
patient survive, it remains impervious to air, and of a very dark 
colour, from the black pulmonary matter, constituting the iron-grey 
induration. Lung in this state sometimes becomes the seat of the 
deposition of tubercles, or sometimes it passes into ulceration without 
any such deposit. 

Having now described the different changes produced in the lungs 
by pneumonia, we shall be better able to understand and appreciate 
the different symptoms by which they are characterized. It may be 
well to bear in mind that they are of a three-fold character — 1, those 
of the inflammatory fever resulting from the inflammation of a 
parenchymatous viscus ; 2, the disturbance in the functions of the 
lungs themselves, as well as of other organs, resulting from the lesion 
of the former ; 3, the changes in the auscultatory phenomena of the 
chest, resulting from the altered condition of the lungs. 

Pneumonia in the first stage is attended by inflammatory fever of 
an active character : this fever commences with rigors and oppression, 
followed, in most cases, by strongly marked symptoms of febrile 
reaction, — giddiness, — sometimes severe headache, with now and 
then delirium, especially towards night, — heat of skin, which is 
almost always of a pungent character, — a full and strong, though 
sometimes rather labouring pulse ; the tongue is furred and somewhat 
congested, urine scanty and rather high coloured ; and there are 
thirst and loss of appetite, with an anxious expression and dusky hue 
of countenance. 



PNEUMONIA — ITS SYMPTOMS. 189 

"With, these symptoms of general fever there are those arising from 
the disturbance of the particular organ ; there is dyspnoea ; not neces- 
sarily any pain in the chest, though this is often present, from the 
frequency of bronchitis of the small tubes ; upon the same circum- 
stance, too, depend the frequency of the cough, and the quantity and 
quality of the expectoration ; so that when this complication is absent, 
all these symptoms may be wanting. Generally, however, in persons 
of tolerably sound constitution, and not very far advanced in life, 
there will be more or less inflammation of the smaller tubes in the 
part of the lung affected, and there will be pain, or rather a feeling 
of soreness in the chest, cough, and expectoration of a remarkably 
viscid mucus, which is of the consistence of thick mucilage, contain- 
ing numerous minute air-bubbles, and adhering so firmly to the sides 
of the vessel containing it, that it may be inverted without its escap- 
ing. This matter may be of every possible colour, sometimes almost 
like white of egg^ more frequently of a rust colour, and sometimes 
tinged with blood ; but it is also not infrequently of a bright gam- 
boge yellow colour, or even bluish or greenish. 

At this period of the disease, we do not commonly have any very 
marked disturbance in the functions of other organs beyond what 
might be supposed to arise from the general febrile disturbance, with 
the exception of (1.) the heat of skin, which is hardly to be ascribed 
to the latter cause, since it is far more frequent than is observed in 
ordinary inflammatory fever, or indeed in any disease, with the 
exception of the early stage of continued fever in young subjects, and 
in the commencement of the exanthems, and in some cases of albu- 
minous urine* The relation, however, in which this state of skin 
stands to the disease in the lungs, has not yet been explained ; 
whether it depends upon an increased evolution of carbonic acid, 
calling for an increased generation of it, and consequent increased 
evolution of heat in the extreme circulation , or whether the inflamed 
lung, excreting less than its usual quantity of this gas, there is less 
heat rendered latent by its evolution in the air-passages, has not been 
shown ; the latter supposition is, however, more in accordance with 
the analogy of other organs. (2.) The derangement in the functions 
of the liver often giving rise to some degree of jaundice ; this, pro- 
bably, arises from engorgement of the hepatic cavae, and consequently 
of the portal vessels, from the impediment to the pulmonic circula- 
tion ; it is said, indeed, to belong more especially to pneumonia of 
the right side ; and if this be true, it must be the result rather of 
contiguity than functional relationship. 

The local or auscultatory sign which characterizes this stage of the 
disease, is a dry crackling sound accompanying each act of respira- 
tion, but heard most distinctly at the termination of the inspiration. 
Various similitudes have been found for this sound, it has been com- 
pared to the noise produced by throwing salt upon red-hot coals ; 
but it is best imitated, as observed by Dr. Williams, by the sound 
which any one makes by rubbing a lock of his own hair near the ear 



* This symptom was first pointed out in its true importance by Dr. Addison. 



190 PNEUMONIA. 

between his thumb and fingers. Several causes have been assigned 
for this phenomenon : some have supposed it to arise from the pas- 
sage of the air through the viscid secretion in the cells, and the 
formation of very minute air-bubbles in them ; others, with certainly 
not less probability, have ascribed it to the expanding of the cells, 
the walls of which have been renderd more stiff by the tumescence, 
and more adhesive by the small quantity of viscid secretion upon 
their surface. Be this as it may, it is certain then that this sound 
(which we shall denominate generally a crepitation, and distinguish 
particularly, as dry crepitation, or pneumonic crepitation) belongs 
especially to the state of lung which we have already spoken of 
under the name of engorgement, whether that engorgement be the 
commencement of inflammation, or whether it belong to a portion of 
lung that has been hepatized, and is in process of return to its natural 
condition. 

It may here be observed that this introduces us to a fresh class of 
sounds, which we shall speak of generally by the name of crepita- 
tion, or crackling. We have already described the ronchus and 
sibilus, which are produced by air in cylinders without liquid, the 
rales or rattles which are produced by air and liquids in tubes ; and 
we now have to do with crepitations, or crackling, which arise from 
the separation or unfolding of membranes which are either rendered 
more unyielding by congestion, or their surfaces more adherent by 
altered secretion. These crepitations may be dry or moist, hard or 
soft ; in the present case we have a dry crepitation, which, when not 
masked by other sounds, cannot fail to be recognised when once it 
has been heard. It generally happens that this crepitation is as- 
sociated with more or less of the sounds arising from bronchitis of 
the smaller tubes ; these, however, do not in ordinary cases prevent 
our hearing the dry crepitation. 

Up to this time there is no diminution in the resonance of the chest 
on percussion, the cells not being sufficiently closed to prevent their 
containing a considerable quantity of air. The signs then which 
belong essentially to the first stage of pneumonia are — inflammatory 
fever, — pungent heat of skin, — dry crepitation without loss of reson- 
ance on percussion : with these are commonly associated pain in the 
chest, cough, and viscid expectoration. 

In the second stage, or that of hepatization, there is for the most 
part a continuance of the fever ; the heat of skin is not necessarily 
present, though it is generally so in practice, since when one part of 
this inflamed mass is in a state of consolidation, there is probably 
some other part in a state of engorgement, either progressing towards 
consolidation or retrograding from it. The disturbance of the func- 
tions of the lungs and other organs, however, becomes greater, there 
is more duskiness of the countenance, owing to the greater impedi- 
ment to the aeration of the blood, the functions of the liver and 
kidneys are also more disturbed. The disease also sometimes proves 
fatal in this stage, and signs of failure of the powers of life may mani- 
fest themselves by the pulse becoming quicker and unequal, or the 
tongue brown and dry; or there may be threatened death from 



SYMPTOMS. 191 

apnoea, evinced by hurried and laborious breathing, livid counten- 
ance, wandering delirium, very small pulse, and clammy sweats. 

The signs furnished by auscultation are very different : the lung 
having now become consolidated, the air is excluded from the 
vesicles, and we have dulness on percussion, the sound of the air 
passing along the tubes becomes audible, and we hear tubular breath- 
ing, and, in the manner already explained (p. 135). The intensity 
with which these sounds may be heard must depend evidently upon 
the continuity of the consolidated portion, and upon its being near 
the surface ; if the consolidation be confined to separate lobules, here 
and there, through the substance of the lungs (a rare occurrence), 
there may be neither tubular breathing nor bronchophony ; or if 
there be a consolidated mass of some size towards the centre of the 
lung, distant tubular breathing may be heard without bronchophony, 
though the latter is scarcely ever audible without the former. In 
ordinary acute pneumonia, however, it almost always happens that 
the inflammation extends to the surface ; thus we have in its second 
stage both tubular breathing and bronchophony. As, however, the 
consolidation of the lung renders audible the passage of the air along 
the bronchial tubes, which could not be heard independently of it, 
so in the same way it gives an increased distinctness to the bronchial 
rattles, which often become under these circumstances remarkably 
characteristic signs. 

We have noticed, already, that lymph effused into the substance 
of the lung may be either of the fibrinous or corpuscular kind, and 
also that it may vary as regards the proportion between its different 
constituents. And there is good reason for believing that effusion of 
serum containing but a small proportion of fibrine or corpuscles, 
sometimes takes place suddenly into the cells, as a consequence of 
inflammatory engorgement of the lungs, and in the place, if we may 
be allowed the expression, of the plastic fibrinous lymph which con- 
stitutes hepatization. This is distinguishable from simple oedema 
or serous dropsy, by its being consequent upon engorgement, and 
preceded by the general symptoms of pneumonia: there are not, 
perhaps, any well-marked signs by which its approach may be antici- 
pated, but it is most to be apprehended in those who are the subjects 
of any visceral disease, especially of the heart or kidneys, and in 
whom, from previous illness, or other circumstances, a deficiency in the 
fibrine and red corpuscles, or a want of constitutional power, may be 
apprehended. Its occurrence is generally attended by increased 
dyspnoea and lividity, often by orthopnoea — a feeble, quick, and 
sometimes intermittent pulse, by much the same symptoms, in short, 
as indicate suffocative bronchitis, from which it is to be distinguished 
by the previous history, and by the signs furnished by ausculation. 
Its stethoscopic signs are dulness on percussion, bronchophony, and 
tubular breathing, not, however, so well marked as in consolidation ; 
and a moist or soft crepitation. 

When consolidation has taken place, the next step in the progress 
of the change in the lungs is, commonly, the grey hepatization or 
puriform infiltration. The general symptoms which attend this stage 



192 PNEUMONIA. 

of the disease are principally those of diminished power, and activity 
in the fever ; the latter of which assumes more of a remittent or 
hectic character ; the pulse becomes soft and the skin generally 
cooler, though there are at times flushings of heat, and often profuse 
perspiration ; the tongue is coated, red, and sometimes glazed, and 
the whole condition of the patient betokens a tendency to exhaustion. 
There is a frequent cough, with generally copious expectoration of a 
puriform character, commonly presenting the nummular appearance, 
though sometimes it looks like uniform pus : this expectoration has 
generally either a very offensive foetid odour, or a peculiar earthy 
one. The stethoscopic signs are just what might be expected from 
the nature of the changes going, on in the lung; namely, a moist 
crepitation, with dulness, tubular breathing, and bronchophony, — the 
three latter, however, being much less distinct than in consolidation. 

When the disease goes on favourably, and the cells of the affected 
portion of the lung become emptied of their adventitious contents 
without injury to the tissue of the organ, the respiration becomes less 
embarrassed, and the tongue more natural ; the hectic subsides, the 
expectoration decreases and gradually loses its unpleasant odour, and 
has less the character of pus and more that of mucus ; the dulness, 
tubular breathing, and bronchophony, as well as the moist crepita- 
tion gradually disappear, and are either succeeded by healthy respira- 
tory murmur, or there is the recurrence of the dry crepitation (rale 
crepitant redux) before the healthy action of the lung is restored. 

It very often happens, however, that the disease takes an opposite 
course, the tissue of the lung becoming disorganized, or the patient 
sinking, without such actual destruction, from the exhaustion attend- 
ing the extensive suppuration : in this case the expectoration con- 
tinues of the puriform character, sometimes becoming intolerably 
foetid, or assuming a pinkish colour from the admixture of blood ; 
the powers of the patient fail, the tongue becomes brown, and the 
pulse more feeble, the stethoscopic signs remaining little altered, 
unless an abscess form from the softening down of a portion of the 
infiltrated lung, in which case there will be gurgling cavernous re- 
spiration, and pectoriloquy. 

The passing of the lung into the state of iron-grey induration is 
not distinctly marked by any characteristic signs: when it takes 
place, the general symptoms of disease subside, but the resonance and 
respiratory murmurs are not restored at the part affected, and bron- 
chophony or even pectoriloquy may remain : the latter is generally 
the result of induration of the lung, which is attended by contraction, 
taking place when the pneumonia has been complicated with pleuritis 
and bronchitis : this contraction of the lung, which has been rendered 
adherent to the ribs by the pleuritis, draws asunder and consequently 
dilates any large tube which may pass through it ; at the same time 
that the occurrence of the bronchitis renders the tube more suscepti- 
ble of such dilatation. 

The symptoms most commonly observed when the lung passes 
into a state of gangrene are a greenish colour of the expectoration, 
which has a most intolerably foetid odour, at the same time that 



DIAGNOSIS. 19 



o 



there is a rapid failure of the powers of life in the patient, the fever 
assuming a low typhoid form. 

Having already given the principal symptoms, both local and 
general, by which pneumonia is accompanied, we may confine our 
remarks upon the diagnosis of this disease to the means of distin- 
guishing it from those with which it is most likely to be confounded ; 
and here it may be observed that pneumonia in its most ordinary 
form is not pneumonia in its most simple form, and that the cough, 
expectoration, and pain in the chest which commonly accompany it, 
and which are generally the symptoms by which the attention of the 
practitioner is directed to the chest, but which, in reality, belong more 
to the capillary bronchitis which accompanies the pneumonia, than 
to the pneumonia itself, are consequently absent when the disease 
appears in its most simple form; in which case it can only be 
detected by a careful exploration of the chest by auscultation. The 
important point then to be borne in mind is, that pneumonia may 
occur without those more obvious signs which are commonly 
received as indicative of its presence, and that we are not to be 
diverted from our examination of the chest by their absence. 

The diseases for which pneumonia is most likely to be mistaken 
under these circumstances are continued fever and certain cerebral 
affections. — From fever it may be distinguished by the greater 
anxiety of the countenance, which, though congested, presents an 
appearance very different from the stupid apathy of the latter dis- 
ease; and although the patient may be confused in intellect and 
even delirious, vet the delirium is different from that of fever, and 
more resembles that which we have noticed as occurring in exten- 
sive bronchitis, the patient being capable of being roused, and 
rationally answering questions for a time, though soon becoming 
confused again. The tongue also presents an important difference, 
being covered with a whitish fur, unlike what is observed in the com- 
mencement of fever. A most important aid in this often difficult 
diagnosis is that furnished by the pungent heat of skin, which we 
have already noticed as belonging to pneumonia in its earlier stages ; 
for this we are indebted to Dr. Addison. It ought not indeed to be 
affirmed that pneumonia is present in all cases in which this peculiar 
heat of skin is found, for it may occur, as we have before said, in some 
other diseases, but where it is present it ought always to direct the 
most careful attention to the condition of the lungs. 

As regards the cerebral symptoms, pneumonia sometimes com- 
mences, especially in the young subject, with intense pain of the 
head, which is very likely, if there be no cough or pain in the chest, 
to divert our attention from the lungs to the brain. In old persons 
again the same error may arise from the disease commencing with. 
active delirium, or a threatening of delirium tremens; in children 
again we may have no obvious symptoms of disease, but such as 
seem to belong rather to hydrocephalus than pneumonia; though we 
must bear in mind that in the latter class of subjects the two dis- 
eases may often be associated. In all these difficulties the pungent 
heat of skin is a great aid, and should suggest a most careful exaaai- 

13 



194 PNEUMONIA. 

nation of the chest; but it must be remembered that in the com- 
mencement of simple pneumonia, when from the period of the dis- 
ease there is no loss of resonance to guide us, the crepitation is often 
not readily heard, and therefore it is necessary to make the patient 
take a very deep inspiration, at the termination of which it may 
generally be detected ; or to ask him to cough, the doing which is 
generally preceded by such an inspiration. 

In the commencement of ordinary pneumonia, which is the only 
sta°;e in which it can be mistaken for bronchitis, the state of skin 
above noticed will be an important guide, to which may be added 
the dry crepitation, and the character of the expectoration already 
described. In the more advanced stages of the disease, the charac- 
teristic signs of pneumonic consolidation should render such a mis- 
take improbable. The pneumonic crepitation, and the absence of the 
stitch in the side, will distinguish early pneumonia from early pleu- 
risy; but the diagnosis between pneumonia that has advanced to con- 
solidation and pleurisy that has gone on to effusion is not so easy ; 
there is, however, more probability of mistaking pleuritic effusion 
for pneumonic consolidation than the converse, and therefore the 
diagnostic signs belong more appropriately to the former, and will 
be explained hereafter. 

[A peculiar form of pneumonic inflammation is liable to occur in 
young children — of a strictly lobular character. It is in all cases 
consequent upon bronchitis or pulmonary catarrh ; and is hence de- 
nominated by Trousseau, who has given a very excellent account of 
the disease, pneumonic catarrh. 

The infant, after having suffered, at short intervals, repeated at- 
tacks of catarrh or bronchitis, often of apparently so slight a character 
as to excite little or no uneasiness, becomes suddenly attacked with 
fever ; its face becomes congested ; its cheeks and lips livid, and its 
skin hot and dry. The ake of the nose are widely, and almost con- 
stantly dilated, and the epigastrium is retracted towards the spinal 
column, causing a deep depression in the region of the diaphragm. 
The orthopnoea rapidly increases, and the pulse acquires an extreme 
frequency; rising often to 120, 140, or 160 in a minute. If the hand 
be applied flat upon the thorax while the child is crying, the vibra- 
tion of the voice will be felt much more distinctly on the diseased 
than on the healthy side. 

In proceeding to auscultate the chest care must be taken not to 
alarm the child. Placed upon the lap of its nurse, the ear of the 
physician can be applied to the posterior and lateral regions of the 
thorax. Most frequently, a sub-crepitant ronchus is heard, pre- 
ceded, sometimes, by a mucous or sibilant ronchus — it is not rare 
to hear crepitation as fine as in the adult. Bronchial respiration is 
heard during expiration ; but it has neither the dryness nor clearness 
observed in the adult. It is most frequently detected towards the 
upper part of the inferior lobe of the lung. The respiratory murmur 
may be heard at several portions of the chest ; it is often absent, after 
the lapse of a few hours, in a part where it had before been distinctly 
heard. This results from the principal bronchial tube leading there 



PKOGNOSIS. 195 

having become blocked up with mucus, so as to prevent the passage 
of the air through it. 

In many cases, this form of pneumonia is of long duration, and 
liable to frequent relapses. It may continue for fifteen to thirty 
days, or even for several months. Acute attacks of it may occur five 
or six times in quick succession; or the diseases may go on, merely 
intermitting in intensity at irregular intervals, until it assumes a 
chronic form and thus continue for six months and even longer. 
This forms an important differential character between it and the 
pneumonia of adults. 

The anatomical lesions are well marked. With inflammation 
and tumefaction of the bronchial mucous membrane, there are pre- 
sent a number of small indurated lobules, between which, the tissue 
of the lungs is healthy. The surface of the lung presents a marbled 
appearance. Besides these indurated lobules, which are confined, 
sometimes, to a portion of one of the lobes, and sometimes invade the 
whole lobe, other lobules are of a violet colour, indicating pneumonic 
inflammation of the first degree ; while, here and there, these masses 
are harder, and form projections when the lung is collapsed. In 
these red lobules, by the aid of the microscope, globules of pus may 
be detected. In addition to lobules in the first and second degrees 
of pneumonic inflammation, there are still others of a yellowish 
colour, in the third stage of inflammation. 

Pneumonic catarrhal inflammation is followed by a special lesion ; 
namely, disseminated abscesses, or small cavities — the air vesicles of 
the luna: dilated, or several of these vesicles broken down — filled with 
pus. The number of those minute abscesses will, in some cases, 
amount to one hundred, or even many hundreds, in a single lung. 
It is often difficult to distinguish between this condition of the lungs 
in the third stage of pneumonic catarrh in children, and a condition 
of these organs, in young subjects, resulting from pulmonary tuber- 
culosis. — Editor.'] 

In forming a prognosis in a case of pneumonia, as of every other 
disease attended with danger, we must keep steadily in view the 
modes of fatal termination, as, by so doing, we shall more readily 
detect the sioms which indicate such a result. Pneumonia is not 
often fatal in the first stage ; it may happen, no doubt, that even at 
this period of the disease the extent of the lung involved may be 
such as to cause death by apnoea, or the intensity of the inflammation 
such as to be fatal by syncope. We have also stated a belief, in 
which, perhaps, all may not concur, that inflammation of the lungs 
sometimes proves rapidly fatal by the state of engorgement passing, 
almost suddenly, into one of effusion into the substance of the lung; 
constituting an inflammatory dropsy of the organ, and causing death 
by apnoea. It more commonly happens, however, that pneumonia 
does not prove fatal before hepatization commences; when, if the 
portion of lung affected be large, and the disease attended by exten- 
sive bronchitis, there often appear symptoms indicating failure of the 
strength, with increasing difficulty of breathing, and death takes 
place from apnoea. This change in the lungs sometimes ensues very 



196 PNEUMONIA. 

rapidly, especially in a subject previously in a feeble state of health, 
and the patient may die in this manner within a week. 

When, however, the danger arising from a tendency to apnoea has 
been escaped, the affected portion of lung frequently passes into the 
state of puriform infiltration, in which case death from sinking, or a 
tendency to failure of the heart's action, is to be apprehended. 

The prognosis, then, of pneumonia is to be founded upon a careful 
consideration of the severity of the attack, upon the presence or 
absence of the signs of the fatal termination which we have described, 
and upon the constitution, age, or other circumstances in the condi- 
tion of the patient, amongst which are to be included complications 
with other diseases. 

When the patient is seen at the commencement of the disease, and 
is of moderately good constitution, and the inflammation not very 
extensive, especially if only one lung be involved ; we may entertain 
a good hope of a favourable termination. If, however, the patient be 
advanced in life, or of generally unsound constitution, if the inflam- 
mation appear to affect a great portion of the lung, and still more, 
if both lungs are involved, or if there exist extensive bronchitis, or dis- 
ease of any other important organs, the danger is great. And even 
in the first stage of pneumonia, if there be delirium or great oppres- 
sion of the nervous system, and if the respiration be hurried, the 
countenance livid, the pulse very frequent and small, and the tongue 
disposed to become brown and dry, we may apprehend death by 
sinking or apnoea, or rather by a complication of both. When hepa- 
tization has taken place, the danger (besides the previous condition 
of the patient which bears upon all stages of the disease) depends 
chiefly upon the extent to which this change has taken place, and 
when that is great, if at the same time there be any of the signs 
already mentioned as indicating much impediment to the respiration 
and tendency to sinking, the prognosis is most unfavourable. At 
this period of the disease a moist and warm perspiration, with a some- 
what increased fulness, but at the same time diminished hardness, of 
the pulse, is a favourable sign, as is also the appearance of a lateri- 
tious deposit in the urine, and may be expected to be followed by the 
further favourable symptoms of a diminution in the dyspnoea and a 
recurrence of a crepitation in the portion of the lung which had been 
rendered irrespirable by the consolidation; and this sound, which 
has been denominated the u rdle crepitant redux" is regarded as a 
sign of retrogression of the inflammation, and of the progress of the 
part affected to its normal condition. 

A good deal of stress has been laid upon the appearance of the 
expectoration in regard to the prognosis; though perhaps, as Dr. 
Addison observes, more is due to the ease and freedom with which 
it is excreted: the sputa losing their very viscid and tenacious 
character, when there are other signs of the retrocession of the dis- 
ease, show that but little remains but the bronchitis ; the appearance 
of a little blood in the expectorated matter is by no means an 
unfavourable sign; but the sudden suppression of the expectoration 
is a very alarming circumstance, and indicates either great exhaus- 



PNEUMONIA — CAUSES. 197 

tion or complete closure of the air-cells through a great extent of the 
lungs. 

At a more advanced period of the disease the presence of pus, 
which has often a most offensive earthy odour, is a circumstance that 
ought to excite great anxiety, though it is not necessarily an 
unfavourable sign. It indicates, in conjunction with the symptoms 
which have been already pointed out (p. 191), the probable occur- 
rence of grey hepatization, or in other words, the softening down 
into pus of the lymph which has closed the air-cells. This change 
may, as we have seen, lead to the ultimate recovery of the part ; but 
as there is great danger of the substance of the lung becoming impli- 
cated in the suppuration, and breaking down at the same time, or, 
what is even more probable, of the patient's powers giving way 
during the process, it bespeaks a very critical condition. In this 
state of things our prognosis must depend mainly upon the powers 
of the patient. If the tongue be tolerably healthy in appearance, the 
pulse of good power, and if there be none of the stethoscopic signs 
of disorganization, but on the contrary, some return of resonance on 
percussion, without any gurgling, though the soft crepitation may 
remain, and still more if the latter give place to the dry crepitation, 
we may hope that the process of cure is going on safely. Here, 
however, we cannot but watch the expectoration with considerable 
interest; the diminution of the fcetor, and of the proportion of pus in 
the expectoration, and subsequently of the quantity of the sputa 
themselves, are favourable signs; but if they become more and more 
offensive, and assume a pinkish or greenish hue, and have not the 
nummulated appearance, but run into one homogeneous mass, we 
may infer that disorganization or even sloughing of the lungs is 
going on; and if at the same time the tongue become brown or red 
and glazed, the pulse quick and feeble, and if there be decided hectic, 
with rapid emaciation, and increasing dyspnoea, the prognosis is all 
but desperate. Dr. Alison remarks, and not without reason, that 
when the hectic, which in a greater or less degree attends the suppu- 
ration consequent upon pneumonia, is protracted beyond three weeks, 
ulceration of the lungs commonly with tubercular deposit may be 
apprehended. 

There can be little doubt, that the greater number of cases of active 
plastic pneumonia in previously healthy subjects are the direct result 
of severe exposure to cold, though in some, and those, too, of the 
most intractable character, there is every reason for believing that the 
disease is set up by the presence of a poison in the blood ; thus it 
often occurs to all appearance spontaneously when the depurating 
action of the kidneys is arrested by disease of those organs ; as well 
as in persons in whom there may be supposed to be an unhealthy 
condition of the blood from other causes ; it occurs also in the progress 
of disease depending upon a morbid poison, as measles, influenza, and 
typhus fever. Pneumonia may also be set up by an irritation of a 
more direct character, as when it supervenes upon tubercles, or is set 
up by the accidental admission into the lungs of substances which 
irritate mechanically, or of acrid gases. 



198 PNEUMONIA — TEEATMENT. 

As an instance of the supervention of pneumonia upon the pre- 
sence of a morbid poison in the blood, we must not omit to notice 
that which occurs apparently in consequence of inflamed veins, or 
suppuration in other parts of the body, in which case the inflamma- 
tion in the lungs rapidly and certainly assumes the suppurative 
character; these cases are generally fatal, though there may have 
been instances of recovery. 

From what has been said of the various results of pneumonia, and 
the different modes in which it may prove fatal, it must at once be 
evident that there must be great difference, or even contrariety, in 
the means required for combating the disease. In acute pneumonia 
in tolerably healthy subjects, the treatment must be decidedly anti- 
phlogistic; that is to say, the recumbent position must be enjoined, and 
the patient restricted to the use of farinaceous diet ; in addition to this, 
the temperature of his apartment should be uniform, and moderately 
warm, from 60° to 65° Fahrenheit. At the same time the easy action 
of the lungs should be insured by careful ventilation, so arranged as 
not to expose the patient to the least current of air. The next step 
should be, in the first stage of pneumonia, to bleed the patient in pro- 
portion to his strength and the activity of the disease. Bleeding 
has an undoubted power in controlling pneumonia in the first stage ; 
and in healthy subjects, therefore, where we have good proof of its 
presence, and where there is no disease of the heart, blood-vessels, or 
kidneys, the patient should be placed in a sitting posture, and blood 
allowed to flow from a vein in a full stream, until the patient feels 
signs of fainting, or until the pulse becomes softer, or if it have before 
been contracted, fuller, or until the sense of oppression about the 
chest is diminished. The abstraction of blood in this stage of the 
inflammation has, in all probability, a double action; in the first 
instance, it has the direct sedative effect upon the heart, and larger 
vessels, which we have already (p. 87) pointed out, as applicable to 
inflammation in general, but also, in the present case, it diminishes 
the quantity of blood sent to the lungs, and thereby lessens the 
amount of function which they have to perform. The relief afforded 
by a full bleeding, thus opportunely timed, is often very striking. 
Sometimes, however, although the breathing has been relieved, and 
the pulse rendered softer, or fuller, the symptoms will again become 
aggravated after some hours, when the venesection may be repeated 
with great effect ; and in some instances there will be little need of 
further treatment. It may be observed here, however, that some- 
times syncope ensues, without any mitigation of the symptoms; a 
circumstance which is generally to be regarded as unfavourable, since 
it shows either a want of power in the system, or else that the extent 
of the inflammation is very great. 

After the bleeding has been performed, and repeated if necessary, 
the next object is to secure a free evacuation of the bowels ; for which 
purpose the combination of rhubarb and calomel, folloAved, if neces- 
sary, by a cathartic draught, or half an ounce of castor-oil, will be 
well fitted. When we have any doubts of the bleeding being well 



ANTIMONY — MERCURY — OPIUM. 199 

borne, it will be a safer practice to cup the patient on the surface of 
the chest, corresponding to the seat of the inflammation, to six or 
eight ounces — a measure which can be repeated if the inflammation 
should continue to extend. 

Before quitting the subject of the use of venesection in pneumonia, 
we would again call attention to the cautions which we have already 
given as to the abstraction of blood, in speaking of treatment of 
inflammation in general, (pp. 90 — 97,) and more particularly to 
opinions expressed that a partial subsidence of the inflammation 
having taken place after blood-letting, in those cases where it has 
afterwards extended, and given rise to effusions of an unfavourable 
character, is no proof that the bleeding has had no ill effect, since it 
may have disposed to an unfavourable termination. 

The remedies which, next in order, demand our consideration are 
antimony, calomel, and opium. The former of these has been much 
recommended by practitioners in various parts of the Continent, more 
particlarly by the French physicians, many of whom are in the habit 
of relying mainly upon it for the cure of pneumonia. The practice 
which they recommend is to give it, in doses, commencing at about 
half a grain, and rapidly increased till irritation of the stomach and 
bowels ensue, after which, if it be persisted in, what is commonly 
termed a tolerance will be established. The late Dr. Thomas Davis, 
however, was in the habit of administering the antimony in doses, 
commencing with one-third of a grain every hour, guarded by a few 
minims of tincture of opium at first, which last was omitted if no 
signs of vomiting ensued, and the dose . of the antimony gradually 
increased till it reached two grains. Now, from the explanation 
which has already been given (p. 98) of the action of antimony on 
inflammation, it might be inferred that in this, the first stage of pneu- 
monia, before the lung has gone into a state of consolidation, the 
antimony would be a most efficient remedy ; and such is found to be 
the case in practice. In the ordinary acute pneumonia of sound sub- 
jects, provided the patient be seen in the commencement of the first 
stage, one or two bleedings, and the continuance of the antimony, in 
doses not exceeding two grains every hour, or hour and a half, will 
often be sufficient to check the disease. In general, the antimony 
acts best when it does not excite vomiting ; and, indeed, the tolerance 
which is found to exist in these doses, which may be called moderate 
when compared with those of the French physicians, is of itself a suf- 
ficient evidence of the propriety of its exhibition. 

It may, however, happen that the antimony will not be borne, or 
that the disease proceeds to the second stage in defiance of it ; and, 
therefore, it is necessary to be provided with another remedy less 
irritating, and of which the operation will be appropriate to any con- 
solidation which may have taken place. Such a remedy we rind in 
mercury. Accordingly, it will be generally found the best practice 
to administer the calomel and opium in the form of the pill already 
recommended, (F. 3 or 4,) twice or thrice a-day, at the same time that 
the antimony is being taken, and subsequently to increase the quan- 



200 PNEUMONIA. 

tity of the calomel according to the progress of disease ; that is to say, 
if the antimony is not borne it may be diminished and the calomel 
carefully increased until some effect is produced upon the system, or 
the disease is manifestly subsiding. 

Even in this stage the disease may, as has been already pointed 
out, prove fatal by apncea, owing to the great extent of lung involved 
in the inflammation. When there is a threatening of such an event, 
a repetition of the bleeding, if the patient can bear it, affords the best 
chance of safety : after the skin has become soft, a large blister should 
be applied to the sternum. Signs of sinking from the extent and 
intensity of the inflammation may also manifest themselves ; in which 
case it will be necessary to administer wine and stimulants, the mer- 
cury and opium being continued, and a blister applied over the 
inflamed portion of lung. 

In most cases we do not see our patients who are the subjects of 
pneumonia, until after the inflammation has proceeded to consolida- 
tion, when the difficulty of combating the disease becomes much 
greater. In this stage our object must still be to check the progress 
of the inflammation, and bring about, if possible, resolution, and pro- 
mote the absorption of the inflammatory effusion ; and in so doing, we 
must endeavour to prevent the occurrence of the third stage, or at 
least to guard against its disorganising consequences ; in other words, 
we must be careful to spare the strength of the patient. Now, here 
bleeding will not exert the same influence over the disease as in the 
stage of engorgement, and there is danger of its too far exhausting 
the powers of life; where, however, there is still considerable heat of 
skin, with a hard pulse, it may be ventured on, especially if there be 
dry crepitation still to be heard. As a general rule, however, it will 
be a safer and not less efficacious practice, to take a few ounces of 
blood by cupping from over the inflamed part of the lungs, and 
repeat the operation should the disease continue to extend ; but even 
this is not to be done, if the pulse be compressible. 

Our next object should be to promote the absorption of the effused 
lymph, which has caused the consolidation. Now, for this purpose, 
we cannot look for much assistance from the antimony, but accord- 
ing to the principles already laid down (pp. 101-103), we may hope 
a great deal from the use of mercury. The French physicians, 
indeed, recommend the tartar-emetic even in this stage, but the prac- 
tice is not generally adopted by those of this country. As in the 
first we recommended the combination of calomel in moderate doses 
with the antimony, so in the second stage the combination of a little 
antimony with the calomel is found to be the most successful treat- 
ment, and to these opium is to be added, to allay irritation, and to 
prevent the calomel from running off by the bowels. The best mode 
of proceeding then is to administer the pill (F. 3 or 4) every three or 
four hours, and in the interval about fifteen minims of antimonial 
wine in a mixture (F. 5). At this period of the disease, a blister 
may be applied with good effect, and repeated in the course of a few 
days. This treatment should be continued until there is evidence of 



TREATMENT OF SECOND STAGE. 201 

the subsidence of the disease, in the diminution of the dyspnoea, and 
in the occurrence of the crepitation before mentioned over the seat of 
the consolidation ; or until a decided effect is produced upon the 
gums ; unless there be signs of the remedy disagreeing. 

When amendment takes place, it will generally be best to diminish 
the quantity of the calomel, or to substitute for it two or three grains 
of blue pill, care being taken not to affect the system powerfully by 
the remedy; which ought also to be withdrawn when there is pus in the 
expectoration, or any of the signs of the presence of puriform infiltration 
or grey hepatization of the lung. Should the remedy be well borne 
after the occurrence of the crepitation of returning respiration, it may 
be cautiously persevered in till that crepitation is succeeded by the 
respiratory murmur of health. 

When, however, it happens that the gums become affected without 
any decided impression being produced upon the disease, the case 
becomes one of greater difficulty. Under these circumstances, if 
there be no signs of the medicine disagreeing, and no hectic or other 
sign of puriform infiltration, keep up a slight effect upon the mouth 
by small doses of some mild preparation for a few days, when, if 
there be no symptoms of any return of the consolidated lung, 
towards its healthy condition, the mercury should be discontinued, 
in which case the counter-irritation should be repeated ; and the 
mixture of extract of conium (F. 23) be employed, to which, if there 
be little cough about a grain and a-half of iodide of potassium may 
be added ; and at the same time a grain of sulphate of quinia may be 
given three times daily. It must be remembered that in this stage 
we may have the iron-grey induration supervene — a result which, 
although not amounting to a perfect cure, places the patient in com- 
parative safety, as no fresh disorganization is likely to ensue until he 
is exposed to some fresh exciting cause of the disease ; and, conse- 
quently, it will be more desirable to favour this result by avoiding 
every cause of irritation, and gently supporting the patient's strength, 
than to run any risk of inducing suppuration by efforts to procure 
absorption, especially by the excessive use of mercury. Patients, 
who have undergone this permanent change in a portion of lung, 
have uncommonly a pale, doughy, and rather anaemic appearance. 

In the stage of puriform infiltration, our object must be to carry, 
if possible, the patient through a process of cure, which, as has 
been already pointed out, is attended with considerable danger ; this 
dansrer arising;- from the texture of the runs; becoming involved in the 
softening which is going on in the effused lymph, and the whole 
mass breaking down together. The object of the practitioner then, 
in such cases, should be to allay irritation, and support the strength, 
of the patient ; for this purpose a bland nutritious diet is essential ; 
good beef-tea and fish, or poultry or game when procurable, are good 
articles of diet ; and where there is not great heat of skin, and the 
appetite tolerably good, a little mutton. Beer, or wine and water, or 
wine may also be allowed, their effects being carefully watched. The 
bowels must be regulated, and if the skin be moist, and there be no 



202 PNEUMONIA — TREATMENT. 

diarrhoea, the mixture (F. 28)* will be of use. When, however, 
there is a tendency to irritability of the bowels, the acid must be 
omitted, and about rive or six grains of sesqui-carbonate of soda may 
be added. If there be much flushing at night, with perspirations 
towards morning, the bark or quinine may be of service, provided 
there be no great heat of skin in the intervals. A good form in 
such cases is the pill (F. 29).f The recovery of the patient may be 
forwarded, when his strength admits of it, by a removal into a pure, 
but mild air ; he must also continue every precaution as to his mode 
of living and the avoidance of exposure to cold, for some time after 
the disease has apparently ceased, which may be known by the pus 
disappearing from the expectoration, and the return of the sounds 
of healthy respiration in the inflamed part, by the patient getting 
flesh, strength, and his natural complexion, and the pulse resuming 
its ordinary frequency. When the tissue of the lung with the effused 
lymph breaks down into suppuration, the case approaches very closely 
to one of phthisis, and must be treated accordingly. 

When a portion of inflamed lung becomes grangrenous, which may 
generally be known by the intolerably foetid smell of the breath and 
expectoration, the case is nearly hopeless ; though there is reason to 
believe that recovery does sometimes take place under the free use 
of stimulants, as wine, bark, ammonia, and asther. 

After all that has been said respecting pneumonia and its treat- 
ment, it should be remarked that the details of the latter are not 
strictly applicable in every particular to the greater number of cases 
in which we have to do with pneumonia of some form or other. The 
fact being that simple acute sthenic pneumonia is by no means a com- 
mon disease. Dr. Watson states that he rarely meets with more than 
five or six cases in a year, and in a vast amount of disease the author 
of the present work rarely finds more. Pneumonia is, nevertheless, 
a disease the consideration of which is of the utmost importance, since 
inflammation of the lungs supervening upon some pre-existing lesion 
is an affair of everyday occurrence. It is set up by the extension of 
the inflammation along the tubes in bronchitis, and by the irritation 
of the tubercles in phthisis, in the progress of which disease it plays 
a very important part. It is brought on by the pulmonic symptoms 
arising from disease of the heart, and it is excited by the state of the 
blood in diseases of the various depurating organs, especially of the 
kidneys. In all these different cases the directions which have been 
given for the treatment of pneumonia will require to be modified 
according to the general condition of the patient. 

* (28) R. Acid. nit. n^ iv. 

Acid. Hydrocklorici, vr^ viij. 
Ext. Conii, gr. xij. — xv. 
Ext. Sarzse. g ss. 
Sjrup. Aurant. g ss. 

Aq. purge, !§ iiiss. Misce. ; of which a third part is to be taken three 
times a-day ; or infusion of bark may be used as a vehicle instead of water. 

f (29) R. Quiniss Disulphat. gr. iss. — ij. 
Pulv. Ipecac, gr. ss. 
Ext. Conii, gr. ij. ss. 
Ft. Pil. ; three or more to be taken daily. 



TYPHOID PNEUMONIA. 203 

There is one form of pneumonia which may be regarded as the 
extreme instance of that condition in which the active antiphlogistic 
measures applicable to the acute sthenic affection are not admissible, 
and in which the very opposite mode of treatment is found the most 
successful ; this is commonly known as Typhoid Pneumonia. This 
form of the disease is often more insidious in its attack than is the 
sthenic ; in some cases it is ushered in by rigors ; but these are as 
frequently wanting, or so slight as to be overlooked, the patient 
merely having complained at times of being cold ; there is commonly 
little or no pain in the chest ; but the respiration is hurried, and the 
patient complains of an oppression of his breath ; there is generally 
headache, and frequently early delirium. The tongue very soon 
becomes brown, and the teeth covered with sordes ; the pulse also is 
very quick and feeble. The skin in the commencement of the dis- 
ease has the pungent heat of pneumonia ; but it is afterwards dry, 
but not very hot ; the expectoration has in the earlier stages of the 
disease the characteristic viscidity ; it is generally of darkish yellow, 
dusky brown, or sepia colour ; it often, however, becomes mixed with 
pus, and not uncommonly assumes a dingy colour, and in a great 
measure loses its viscidity ; the sputa running, as it were, together, 
and being of a uniform opaque dirty green, or brown character, of 
the consistency of thick gruel, with not uncommonly of a foetid odour. 

The changes which are meanwhile going on in the lungs are, in 
the commencement, not very unlike those of acute pneumonia. There 
is first engorgement, but this engorgement is rather that of conges- 
tion than of inflammation ; at all events, it does not give rise to the 
characteristic effusions of the latter, and possibly it is on this account 
that little or no crepitation is to be heard ; what there is, is of a softer 
or moister character. In the next stage, the inflamed lung, instead 
of becoming consolidated by the effusion of plastic lymph, presents 
more of a soft pulpy consistence, not unlike that of the spleen. If, 
however, the inflammation be not at the very base of the lung, there 
will be bronchial respiration and bronchophony. The tendency of 
this form of inflammation is to disorganisation, generally in the form 
of purulent infiltration, and breaking down of the tissue of the lung ; 
it more often happens, however, if the disease be not arrested, that 
the patient dies with symptoms of exhaustion before those changes 
can take place. Typhoid pneumonia is very apt to assume the lobular 
form, affecting many separate lobules through the lung. "When this 
is so, there will rarely be crepitation audible in the first stage, or 
bronchophony in the second, and the diagnosis is consequently very 
obscure. When, however, the patient is seen early, the viscid ex- 
pectoration, and still more the pungent heat of skin, will enable us 
pretty surely to suspect what is going on ; but where this is not the 
case, it is often next to impossible to distinguish the disease from low 
continued fever. It is fortunate, however, that the confounding this 
disease with fever, and treating it accordingly, is an error of far less 
practical consequence as regards the life of the patient than that to 
which those are liable who are guided solely by physical signs, and 
having by these detected pneumonia, would proceed to treat the 



204 TREATMENT. 

typhoid as the acute. It is rarely, if ever, that depletion can be borne 
in any stage of typhoid pneumonia, and it is only at the commence- 
ment that milder antiphlogistic measures are admissible; but it is 
very desirable to induce a gentle action of the skin and kidneys, and 
to allay irritation at the same time ; care being taken not to depress 
the strength of the patient. It has been recommended to administer 
the tartar-emetic in pretty fall doses, and bark or quinine in the in- 
tervals. In general, however, the bark will not be well borne while 
the tonge is coated and the skin hot, and the best practice will be found 
to be the exhibition of acetate of ammonia (F. 30),* with a diuretic 
and light tonic or diffusible stimulant ; small doses of ipecacuanha or 
antimony may be combined with it at the commencement of the 
attack. Owing to the disorganising tendency of the ' disease, mer- 
curials must be used with great caution. A grain of calomel may be 
given twice or thrice a day, with a quarter of a grain of tartar-emetic, 
and a grain or half a grain of opium, according to the state of the 
bowels and the tendency to delirium ; but the mercury should be 
carefully watched and withdrawn so soon as there is the least appear- 
ance of any action upon the mouth, or there is reason to apprehend 
any suppuration in the lungs. Care should be taken from the first to 
support the patient by light nourishment, such as good animal broths 
and nutritious farinaceous food ; but when the pulse begins to get 
more feeble, and the skin less hot, a little wine may be allowed, and 
if the circulation be not very feeble, a blister may be applied over 
the inflamed part, and at this period of the disease, also, ammonia 
may be added to the medicine, and the ipecacuanha or antimony 
withdrawn ; and if the circulation continues to fail, the compound- 
sulphuric a3ther may be substituted for the nitric ; the wine also may 
require to be largely increased as the typhoid symptoms become 
more urgent ; and it not very rarely happens that the patient in 
this apparently-hopeless condition recovers under the free use of 
stimulants. 

The form in which pneumonia most commonly presents itself in 
large towns, is one which we should be inclined to regard as inter- 
mediate between the sthenic and the typhoid. It has not the hard 
pulse and white tongue of the sthenic, though it has not the signs of 
prostration which attend the typhoid. The auscultatory signs are 
however those of active pneumonia. These cases might no doubt be 
made typhoid by the use of the lancet ; but they generally do well 
with moderate doses of calomel with antimony and opium, or even 
hydrarg. c. cret. and Dover's powder, aided by a saline and anti- 
monial draught ; a blister being applied after the skin has become 
perspirable. 

* (30) R. Sp. Mth. nit. 3 ss. 
Tinct. Hyosc. ttl xx. 
Liq. Amnion. Acet. g iij. 
Mist. Camphorse, vel. 
Infus. Serpentarise, J j. 
Ft. haust. ; to be taken every fourth hour. To this the sesquicarb. ammon may be 
added, in doses of from two to five grains. 



PLEUKITIS. 205 



PLEUEITIS. 



As pleurisy or pleuritis consists essentially in inflammation of the 
pleura or serous membrane which invests the lungs and lines the 
walls and floor of the chest, and as the symptoms are for the most 
part directly connected with the changes resulting from that inflam- 
mation, it will be best, in treating of this disease, to commence with 
the description of the latter. The first stage of inflammation of this, 
as of every other serous membrane, is that of congestion or hypersemia, 
in which the membrane assumes a red colour, in consequence of the 
apparently-increased number of vessels ramifying immediately un- 
derneath its surface, this appearance depending, as has already been 
explained, upon the enlargement of the minuter capillaries, enabling 
them to admit the red corpuscles of the blood. It is not often, except 
in the case of accidents, or when the patient is cut off by some other 
» disease at the commencement of an attack of pleurisy, that we have 
an opportunity of seeing the membrane in this condition. Such ap- 
pearances have, however, under such circumstances, been ascertained 
to exist, and when an animal has been opened very soon after inflam- 
mation has been artificially excited in the pleura. At this time, so 
far from there being any effusion, the membrane is dryer than in 
health. This condition may either continue only a few hours, or may 
endure for several days, according to the greater or less intensity of 
the inflammation, or the greater or less strength of the constitution of 
the patient. The characteristic effusions of the inflammation then 
begin to show themselves. Now, it may be as well to bear in mind that 
these consist essentially in the first place of inflammatory lymph ; though 
this lymph admits of every possible gradation, from plastic fibrinous 
lymph to corpuscular lymph with abundance of fluid. The plastic 
effusion generally first makes its appearance in thin layers or flakes 
upon the surface of the pleura, of a gelatinous consistency, these 
gradually becomes firmer, the fluid part either becoming absorbed or 
subsiding to the more depending part of the cavity. The more solid 
portion which is thus left adherent to the surface of the pleura is at 
first of a greyish-white colour, and somewhat pasty consistency. The 
layers or flakes of this substance have at this period a soft villous 
appearance, and may be readily peeled off from the inflamed mem- 
brane, leaving it red with stellated vessels. The serum is of a pale 
straw colour, at times transparent, and at others rendered turbid by 
the admixture of minute shreds of fibrine, and in some rare instances 
is coloured with blood. This then constitutes what may be termed 
the second stage of the disease, in which we have the soft villous 
layers of lymph adhering to the pleura, and the serous fluid above 
described gravitating in a greater or less quantity to the lower part 
of the cavity. From this stage the disease may follow several dif- 
ferent courses. 

In tolerably good constitutions the lymph becomes organised ac- 
cording to the process already described (pp. 53 et scq.). Now, we 



206 ITS PATHOLOGY. 

have already seen that if two surfaces of serous membrane, one of 
which is the seat of inflammation, are in contact, as would ordinarily 
be the case with regard to the costal or diaphragmatic, and pulmonic 
pleura, the inflammation extends by contiguity, and where there is a 
layer of lymph poured out upon one surface, the same takes place 
upon the opposed, and the minute vessels of each, which are formed 
in the process of organisation, inosculate with each other and thus 
adhesion is established. If, however, there is a large proportion of 
serum effused with the lymph, or in other words, if the effused liquor 
sanguinis contains a large proportion of fluid, the two surfaces will 
be kept asunder, and the adhesion prevented ; in which case the soft 
villous coat already mentioned as adhering to the pleura undergoes 
the ordinary changes of effused lymph, becomes firm, and assumes 
the properties of areolar tissue, and thus a new or adventitious layer 
of false membrane (as it is frequently termed), is formed either upon 
the surface of the lining of the chest, or of the coating of the lung. 
The time required for the formation of these coverings of new areolar 
tissue is exceedingly various ; in some cases they are formed in a 
few days, and in others not within several weeks. Generally speak- 
ing, the plastic power is the greatest, and therefore early organisation 
is more to be expected, in young and robust, than in debilitated sub- 
jects. There is also a great variety in the extent to which these 
membranes may be effused ; sometimes they cover the whole lung, 
and line the whole of the walls and floor of the cavity. There is 
also a great variety in the thickness of these membranes : sometimes 
they are scarcely thicker than the serous membrane itself; at others 
they consist of several layers, amounting to two or three or more 
lines in depth. 

One remarkable property of these membranes, to which allusion 
has already been made, is their tendency to contract ; and when the 
costal pleura is lined by a tolerably thick layer of lymph, whether 
that layer be adherent to the corresponding portion of the pulmonic 
pleura or otherwise, there will often be a drawing together of the 
ribs on that side, causing flattening of the chest and some amount of 
lateral curvature of the spine. When there is a large quantity 
effused, separating the lung from the ribs, absorption may take place, 
and the contact between them being restored, the contraction above 
spoken of will ensue. Sometimes, however, this absorption is sus- 
pended, and the side, instead of contracting, bulges out from the 
great accumulation of fluid ; one effect of which is, that the lung is 
compressed against the bodies of the vertebras, so as in some cases 
entirely to exclude the air, and give it the appearance of a dense 
fleshy mass, which, however, unless constricted by the false mem- 
brane, is capable of being again inflated ; in this condition it is said 
to be carnified. 

When this effusion is upon the left side of the chest it often presses 
so strongly upon the mediastinum as to thrust it, and the heart with 
it, to the right side, so that the latter may be felt beating to the right 
of the sternum ; sometimes, when it is on the right, the dislocation 
towards the left is perceptible ; in the latter case, too, it often thrusts 



ITS GENERAL SYMPTOMS. 207 

down the liver, so as to give the appearance of enlargement of that 
organ. When the fluid remains in the cavity of the chest for a con- 
siderable time, or when it occurs in an unsound constitution, it com- 
monly assumes a puriform character, presenting every possible 
gradation between serum rendered turbid by the presence of a few 
pus globules, and perfect pus ; this is termed empyema. When an 
empyema is thus established, the false membrane by which it is 
lined assumes the characters and properties of pyogenic membrane, 
and continues to secrete pus. This pus is commonly free from offen- 
sive odour as long as the air is excluded ; but when any has been 
admitted, the fluid generally becomes intolerably foetid. Both these 
statements, however, admit of exceptions. When the cavity of the 
pleura is thus filled with pus, it often happens, that, after a time, 
there is a bulging in one of the intercostal spaces, generally rather 
low in the chest, as between the sixth and seventh, or seventh and 
eighth ribs ; which soon fluctuates upon being handled, and has all 
the appearance of an abscess pointing, as it is termed. If this be not 
opened by the knife, the pus makes a way for itself by ulceration, 
and thus escapes (a portion of it at least), spontaneously. Unless, 
however, the lung .expand sufficiently to fill up the cavity of the 
pleura, which is rarely the case, the pus cannot all flow out, unless 
its place is refilled by air, and this is one way in which air is admitted 
into the cavity of the pleura, constituting what is termed a pneumo- 
thorax. Sometimes, again, but not so frequently, ulceration takes 
place through the pleura covering the lung, and thus the pus finds 
its way into the substance of that organ, and occasionally produces 
death by suffocation ; at others a communication is established with 
a bronchial tube, and thus a large portion of the pus is got rid of by 
expectoration; at the same time that a pneumothorax is established 
by the admission of air through the opening. The fluid does not 
always move freely in the cavity of the pleura, as it is not uncommon 
for adhesions to form around an effusion either of serum or pus, con- 
stituting what is termed a circumscribed empyema. When an 
empyema of this kind points outwardly, or is opened by the surgeon, 
or when it opens by ulceration into the lung, there can be no exten- 
sive admission of air into the cavity of the pleura, and the lung is 
prevented from collapsing by the circumscribing adhesions. 

Such are the principal structural changes in the pleura caused by 
inflammation of that membrane. It will be well next to connect 
these changes with the symptoms observed in the course of the dis- 
ease. Pleuritis then commonly is ushered in by the ordinary signs 
of inflammatory fever, as pain in the limbs, rigors followed by heats, 
head-ache, scanty and high-coloured urine ; the tongue is white and 
furred,*the pulse rather hard and frequent, the skin hot but disposed 
to be moist, and differing much from the pungent heat of pneumonia. 
With these signs of constitutional disturbance there is first felt in the 
chest, and most commonly at the seat of the inflammation, a sharp 
pungent pain which often seems to shoot in various directions. This 
pain is always increased by drawing a deep inspiration, whence it is 
familiarly known as a stitch ; by coughing, and often, though not 



208 PLEUEITIS. 

always, by pressure upon the part affected. The pain gradually 
increases in severity ; it is most severe in persons of vigorous consti- 
tution, but in some leucophlegmatic subjects the disease often creeps 
on insidiously, and with so little pain, that it is at first nearly over- 
looked. When the inflammation is near the apex, the pain is often 
very slight, but when near the angle between the ribs and the dia- 
phragm, or upon the diaphragm itself, it is commonly most intense. 
There is sometimes considerable tenderness upon external pressure, 
in which case the patient lies most easily upon the sound side, gene- 
rally with the shoulders rather raised so as to cause a curvature of 
the spine with the concavity towards the affected side. Often, how- 
ever, there is no tenderness, in which case the easiest position is on 
the affected side, as the pressure thus produced, helps to keep the 
ribs at rest, and in some degree prevents the pain which is caused by 
the respiratory movements. The expression of the countenance 
is very remarkable, being that of a peculiar smile or grin, to which 
the term risus Sardonicus has been applied ; it arises no doubt from 
the constrained mode of breathing and the continued apprehension 
of taking an inspiration, sufficiently deep to cause the sharp lancin- 
ating pain which commonly attends it. 

The constrained movement of the ribs and diaphragm which is thus 
produced furnishes one of the most interesting signs of this disease, 
though one which has not till lately, received the attention which it 
deserves, and for the elucidation of which the profession is mainly 
indebted to Drs. Hutchinson and Sibson, though its importance in 
connection with the aetiology of disease was noticed in the Guy's 
Hospital Report of the year 141,* and subsequently in the Guls- 
tonian Lectures. When the inflammation affects the pleura costalis, 
or a corresponding part of the pleura pulmonalis, the ribs on that 
side are nearly fixed, but the movement of the diaphragm is not 
impeded, and the respiration is abdominal ; when, on the other hand, 
inflammation affects chiefly the pleura covering the diaphragm and 
that over the base of the lung, the respiration is, for similar reasons, 
thoracic, or more commonly carried on almost entirely by the upper 
ribs ; often, however, the respiratory movement of either part is rather 
diminished than altogether arrested, and for the purpose of measuring 
the diminution a very ingenious instrument has been contrived by 
Dr. Sibson. 

The next condition to be investigated is the respiratory sound: 
now, as has been already observed, the two surfaces of the pleura 
glide, in health, so smoothly over each other that no sound is elicited. 
In the earliest stage of the inflammation, before any effusion is pro- 
duced, the natural secretion of the part being diminished or arrested, 
it is reasonable to expect that there may be some slight friction 
sound ; and such a sound is stated by some authors to be one of the 
diagnostic signs of this stage of the disease; it may, no doubt, be 
sometimes heard, but it is very faint, and owing to the diminished 

* Vide Guy's Hospital Report, vol. vi., p. 235, et seq., and Gulstonian Lectures, by 
G. H. Barlow, M. D., in Med. Gazette for 1844. • 



SIGNS OF EFFUSION OF LYMPH. 209 

motion of the part it is but rarely heard, and therefore but little 
value is to be attached to it in practice. 

It is, however, in the next stage, that of effusion of liquor san- 
guinis, or inflammatory lymph, when the general or constitutional 
symptoms are but little altered, that the auscultatory, or one might 
say the physical signs generally, are of value ; and we need merely 
revert to the statements already made, respecting the different forms 
which the inflammatory lymph may assume, to make it at once appa- 
rent that we shall have corresponding differences in the physical 
phenomena. 

Let us take first the case of the effusion of fibrinous lymph with, a 
small quantity of serum, which is quickly absorbed. As the pain 
and tenderness of the membrane remain as at the commencement, the 
diminished mobility of the part will also continue, and the resonance 
will be but little affected ; but we shall have the first unequivocal 
instance of those friction sounds to which allusion has alreaclv been 
made. In the earliest condition of the plastic lymph, as already 
described, it is soft and villous, not indeed moving with the ease and 
noiselessness of the healthy membrane, but not yet capable of pro- 
ducing any rough or grating sound. When, therefore, the ear or 
stethoscope is applied to the surface of the chest near the part which 
is in this stage of inflammation, we hear a very soft sound, which 
indeed can only with difficulty be distinguished from a moist crepita- 
tion or a fine bronchial rattle; when, however, the new membrane 
becomes firmer from the further absorption of the serum, the friction 
sound becomes rougher, and, as it were, dryer, sometimes resembling 
the rubbing of the cuffs of the coat together, and sometimes having 
quite a rasping sound. In the latter instances, where in fact we have 
the friction produced by the tougher and nearly organised membrane, 
a vibration, or " fremissement," may be distinctly felt by laying the 
fingers in the intercostal spaces over the part affected. When the 
inflammation is situated in the diaphragmatic pleura, and that part of 
the pulmonic pleura which is in apposition to it, there will of course 
be but little if any friction sound to be heard ; and, unless it extend 
up the side of the chest, or there be effusion of fluid in sufficient quan- 
tity to make its presence apparent by the characteristic physical signs, 
we can derive but little aid from the stethoscope, and consequently 
the diagnosis becomes much more difficult. Under these circum- 
stances, however, we may obtain much assistance from the general 
symptoms of serous inflammation, with the exception, however, that 
the pulse is often very small, contracted, or, as it is termed, wiry; 
and the general distress and expression of anxiety more intense; 
indeed, there appears to be a remarkable tendency in inflammation 
of the diaphragmatic pleura to depress the moving powers of the 
circulation, not unlike that which we shall hereafter have occasion 
to notice as accompanying inflammation of parts immediately below 
the diaphragm. Another important aid to the diagnosis in such cases 
is to be found in the altered mobility of the ribs ; the diaphragm on 
the side affected (and it is not uncommon for this form of pleurisy to 
attack both sides) is nearly fixed, as are also the four inferior ribs, 

u 



210 PLEURITIS. 

termed by Dr. Sibson the diaphragmatic ribs. After all, however, it 
will remain very difficult, and in some cases next to impossible to 
distinguish between diaphragmatic pleurisy and other inflammations 
in the same region of the body, or immediately below the diaphragm ; 
especially inflammatory affections of the peritoneum covering neigh- 
bouring structures, since the immobility of the lower ribs and dia- 
phragm and the depression of the circulation will often be the same. 

When the effused lymph has formed adhesions between the two 
apposed surfaces of the pleura, the friction sounds will generally 
cease, but there will commonly, for a short time afterwards, be a 
creaking or leathery sound accompanying a deep inspiration; this 
will often continue with greater or less intensity till the new mem- 
brane has become organised, when the inflammation may be said to 
have ceased, and we have to do only with its permanent effects. 
There will also be immobility, or diminished mobility, of the ribs 
or diaphragm, according to the part affected ; and where the lymph 
is very thick between the two surfaces of the pleura there will be 
defective resonance, owing to the diminished elasticity of the walls 
of the chest, but not the almost perfect dulness of large serous effu- 
sion, or extensive pneumonic consolidation. 

When, however, as very often happens, the serum is not absorbed, 
and remains in considerable quantities in the cavity of the pleura, we 
have a different set of phenomena. If it be not circumscribed by 
adhesion it subsides to the lower part of the chest, raising in some 
measure the lung, which, when not consolidated by disease, is speci- 
fically lighter than the fluid; when the latter is not in any large 
quantity, there is no great impediment to the function of the lung, 
and consequently the pulse and respiration are but little affected ; as, 
however, the quantity of the fluid increases, the respiration becomes 
much embarrassed ; and since owing to the compression of one lung, 
the quantity of blood in the pulmonic circulation is much diminished, 
the quantity returned to the left side of the heart must be so like- 
wise ; and consequently the pulse becomes either very small, irregu- 
lar, or intermitting. Another effect of the diminished function of 
respiration and impeded pulmonic circulation is the imperfect aera- 
tion of the blood, and consequent lividity of the lips and tongue, 
with congestion of the countenance. This obstruction of the pulmo- 
nic circulation also produces its ordinary results — obstruction to the 
return of the blood in the veins, and, when long continued, anasarca, 
generally of the most depending parts, engorgement of the right 
heart and portal circulation, scanty urine, and general derangement of 
the secretions. The position also of the patient may assist us in 
detecting pleuritic effusion; respecting this a good deal has been 
written, though not always very clearly. When there is much fluid 
in either cavity, it must necessarily happen that th« pressure, not 
only upon the lung on the side affected, but also upon the mediasti- 
num and through it upon the opposite lung, must be increased by 
the recumbent position, and consequently there is most commonly 
orthopnoea, or if not that, a necessity for a semi-erect position. 
When, however, the quantity of the fluid is not very great it is rea- 



SIGNS OF EFFUSION. 211 

sonable to expect that the pressure upon the opposite lung will be 
the least, and consequently the respiration the easiest when the 
patient lies on the affected side. Generally, however, owing pro- 
bably to the larger hollow which is formed between the bodies of the 
vertebrae and the angles of the ribs, the patient lies easiest not exactly 
upon, but towards the affected side, in a diagonal posture, as Andral 
has termed it, resting in fact mostly upon the angles of the ribs of the 
affected side. Still there are many exceptions to this rule, depending 
partly, no doubt, upon the presence of adhesions, and partly upon 
the condition of the opposite lung ; so that cases are not very uncom- 
mon in which the patient may lie indifferently on either side, although 
one pleura may be quite full of fluid, and in some the patient even 
lies the most easily on the sound side. 

It is true, indeed, that all the above symptoms may arise from 
other causes than effusion, and therefore to these must be added the 
signs arising from the physical changes, which may be detected by 
inspection, manipulation, and auscultation. 

Now, effusion into the pleura in large quantities almost always 
causes a fulness of the ribs on that side, which may generally be per- 
ceived by inspection. It must not be forgotten, however, that it has 
been stated that the contraction of false membrane, formed by pleu- 
ritis, causes a drawing in of that side or bending of the spine towards 
it, the effect of which is to give an appearance of a bulging of the 
ribs on the opposite side ; and it is no imaginary case for the contrac- 
tion of the plastic effusion of a pleuritis on one side to have given 
rise to the suspicion of a large effusion of fluid on the opposite. Not 
only is there this bulging of several of the ribs together, but there is 
often a degree of protrusion of the intercostal spaces beyond them, 
producing an appearance, especially in the lean subject, the very 
opposite of that which is commonly observed, namely, of these spaces 
being more prominent than the ribs; this is accounted for, by Dr. 
Stokes, upon the principle that the intercostal muscles lose their con- 
tractility, and consequently the power of resisting the pressure of the 
fluid within the chest, by their being overlaid by an inflamed mem- 
brane. And there is, no doubt, much truth in this explanation, but 
it is to be regarded rather as an illustration of an interesting patholo- 
gical law, than as an aid to diagnosis ; since the fluid effusion may be 
present, but it may have been poured forth by a part different from that 
at which it produces the greatest lateral pressure ; as, for instance, the 
inflammation may have been in the pleura covering the diaphragm, 
but the effusion, if abundant, may ascend up the sides of the chest, 
and the pressure would be in the same situation as if the fluid had 
been poured out by inflammation of the costal pleura, but the inter- 
costal muscles would not in this case have lost their contractility, 
and consequently no protrusion of these spaces would ensue. The 
bulging of the ribs may be more satisfactorily determined by com- 
paring the corresponding measurements of the two sides, though it 
may be observed that this requires the greatest caution in adjusting 
the tape or whatever is used. 

Considerable aid in the diagnosis of effusion may also be obtained 



212 PLEURITIS. 

by manipulation or manual examination of the chest and hypochon- 
dria. When the hand is placed upon the ribs of a person in health, 
while speaking, a peculiar thrill or vibration may be felt which has 
been termed the tactile vibration of the voice. This vibration is no 
doubt greater in some persons than in others, as in thin than in 
corpulent subjects; it is less also in old than in young subjects, and is 
diminished by thick and firm adhesions, but in none of these cases 
is it obliterated, which however it is completely when there is any 
considerable quantity of fluid in the pleura. When this is the case, 
and the palm of the hand is laid upon the lower ribs, vibration will 
not be felt in the slightest degree, and its absence may be rendered 
more striking by contrasting it with the opposite side ; and it will be 
more or "less extensive according to the amount of effusion, and may 
generally be most plainly perceived over the angles of the inferior ribs. 
By manual examination the position of the heart may also be ascer- 
tained, and the presence of fluid in the left side often detected by its 
being thrust to the right; the dislocation of the heart towards the 
left side by fluid in the right pleura is not so obvious, and can only 
be observed when the fluid is in great quantity. The motion of the 
abdominal parietes in respiration should also be explored by the 
hand for the reasons already explained; though it should be remem- 
bered that other diseases will interfere with the descent of the dia- 
phragm. 

Percussion affords most important aid in detecting the presence of 
fluid in the pleura; as the resonance of the chest is diminished or 
impaired according to the amount of the effusion. It must be remem- 
bered, however, that a considerable quantity may be present at the 
base of the cavity without its being detected, in this manner, espe- 
cially on the right side, where the neighbourhood of the liver always 
causes a greater or less degree of dulness. When the quantity of the 
fluid is great, but not sufficiently so perfectly to destroy the reso- 
nance of that side of the chest, the dulness is commonly at the lower 
part, when the patient is sitting up, and may be traced in nearly a 
horizontal direction to the anterior. When the patient lies on his 
back the fluid will of course gravitate towards the posterior part of 
the cavity, and the dulness may be observed ascending more or less 
towards the anterior part of the chest, which, when the fluid is not in 
very great quantity, Avill have become resonant, and this will aid in 
distinguishing it from the fixed dulness resulting from pneumonic 
consolidation; this sign, obtained from the shifting of the fluid, is not 
of universal application, and although its presence may be looked 
upon as conclusive in support of the question of effusion, its absence 
is not so against it. 

The most important of the physical signs of pleuritic effusion are 
those derived from auscultation. The principles which give rise to 
these characteristic phenomena are, that the effused fluid compresses 
the lung so as in some parts to prevent altogether its inflation in in- 
spiration, and in others to modify the sounds of respiration ; secondly, 
that the effused liquid is a far better conductor of sound than the 
spongy texture of healthy lung ; and lastly, that the vibrations of 



SIGNS OF EFFUSION. 213 

the fluid give a peculiar character to the sounds of the voice and 
respiration. 

According to the first of these principles, we find that the respira- 
tory murmur is commonly absolutely silenced in the part most com- 
pressed by large effusion, as in the lower lobe when the patient is in 
the erect posture ; whereas in the upper part of the lung, which is 
pressed against the walls of the chest, the vesicular murmur of re- 
spiration is more or less diminished, at the same time that the con- 
ducting power of the lung is increased; the effect of which is to 
render the respiratory sound coarse and rather hissing. The sound 
of the air passing through the bronchi is also rendered more audible 
from the same cause : this, however, can only be the case where the 
lung is but little compressed, since the greater the compression, the 
less must be the amount of air passing through the tubes ; therefore, 
when the patient is in the erect position, bronchial respiration is to 
be heard only at that portion of the chest which lies near the upper 
boundary of the fluid (as indicated by dulness on percussion), and 
that not with the same degree of intensity with which it may be 
heard in consolidation of the lung. It should be remembered that as 
the lung is connected with the walls of the chest, near the bodies of 
the vertebras, it must, when there are no adhesions, recede from the 
ribs when pressed upon by fluid, but as this pressure will be the 
greatest at the lowest part, it will be more compressed, and also 
recede further from the parties at the base in the erect position, and 
will approach more closely to them higher up ; and, except in cases 
of very great effusion, such as are rare when it is of an inflammatory 
character, there will be contact between the surfaces of the pleura 
above the fifth or fourth rib, the result of which must be a layer of 
fluid between the lung and the ribs, diminishing in width from below 
upwards : the effect of this is to give a coarse and rather hissing 
sound to the respiration above the highest line of the fluid : below 
this there will be little, if any, vesicular murmur, but the respiration 
will be tubular or bronchial, and at the same time distant, that is to 
say, not appearing to proceed to the ear from a point immediately 
below the ribs, but some distance beyond them ; but lower still, 
where the stratum of fluid is of the greatest width, there is scarcely 
any respiratory sound to be heard. 

It is well here to point out, that as the compression, and conse- 
quently the diminution of the respiration, is the greatest at the lowest 
part of the lung, there can be little air passing through the bronchial 
tubes above ; which is one reason of the bronchial respiration not 
being so distinctly heard as in the case of pneumonic consolidation, 
where there is respirable lung beyond the consolidated part, and 
therefore air passing freely along the tubes which traverse it. As 
regards the voice, however, the case is different, for, as was remarked 
when we spoke of pneumonia, its sounds are not rendered audible at 
the surface of the chest by the transit of the air through the tubes, 
but by the propagation of the sonorous vibrations along the tubes ; 
Avhich vibrations, though they are not sufficiently intense to be heard 
through the healthy lung, become audible when there is condensed 



214 PLEUKITIS. 

lung interposed between the liquid effusion and the tubes and the 
walls of the chest, and thus it is that the vocal sound already de- 
scribed by the term bronchophony, is produced ; the bronchophony 
being the most distinct some little way below the highest line of the 
fluid, where there is sufficient compression to condense the lung 
around some of the tubes nearest the surface of the pleura, but not 
sufficient to obliterate the tubes, or greatly to obstruct the sound. 
"We have stated that the effused fluid has a peculiar effect in modify- 
ing the sound produced by the voice in the tubes : this consists in 
giving it a remarkable vibrating or tremulous sound, which we pro- 
pose to term tremulous bronchophony. Laennec compared the sound 
sometimes heard under these circumstances, to the bleating of a goat, 
and called it oegophony ; but this is a sound which we can very 
rarely hear, though when heard, it is most striking, and may be re- 
garded as pathognomonic. Its rarity is probably owing to a definite 
depth in the layer of fluid, and perhaps also a fixed size of the tube 
being required for its production. The more ordinary tremulous 
bronchophony, or, as some have termed it oegophonic bronchophony, 
is a sound which may almost always be heard where there is a mo- 
derately thin layer of fluid between the ribs and the lung ; it is 
generally discoverable from the line where the resonance begins to 
diminish, to where the respiratory sound is altogether lost, and is 
one of the most constant and distinctive signs of pleuritic effusion, if 
not the most so. 

Such are the principal signs of fluid in the pleura, by which such 
effusion can commonly be recognised. As, however, the diagnosis 
between this and the dulness arising from pneumonic consolidation 
is one of considerable practical importance, it will be well briefly to 
recapitulate the points of difference. 

1. In the first place, the previous cause of the disease, as far as it 
can be ascertained, is of some assistance. In pneumonia there is not 
necessarily pain in the side affected, and when present, it is not 
severe, whereas that of pleuritis is sharp and pungent; in the pro- 
gress of pneumonia there will generally have been the rust-coloured 
viscid expectoration, in pleurisy there is little or none ; the occurrence 
of this expectoration does not, however, prove that the dulness in 
question arises from pneumonia, since, though this disease may be 
present, the probability is rather in favour of its being complicated 
with pleuritis. 

2. Pleuritic effusion often distends the cavity, and either causes 
elevation of the intercostal depressions, displacement of the heart, 
or depression of the liver, none of which occur in pneumonic con- 
solidation. 

3. When the quantity of effusion is not so great as to render the 
whole side of the chest dull upon percussion, there will be a tremulous 
bronchophony a little below the upper line of dulness ; and in the 
same situation tubular breathing mav be heard likewise, but below 
this line the sounds of the voice and respiration are silenced alto- 
gether ; in pneumonic consolidation, on the other hand, the dulness, 
and bronchial voice and respiration are generally coextensive. When 



ITS CAUSES. 215 

the quantity of fluid is such as to caxise universal dulness, the sounds 
of respiration will be altogether silenced, although those of the voice 
may still be heard over the upper part of the lung, and we shall have 
the further distinction, in the case of effusion, of — 

4. The absence of the tactile vibration, which, on the other hand, 
is not at all diminished by pneumonic consolidation. 

It must be remembered, however, that although in the majority of 
cases, the diagnosis between pleuritic effusion and pneumonic con- 
solidation is comparatively easy, yet in some instances, amongst 
which may be reckoned effusion circumscribed by adhesion, the dis- 
tinction is next to impossible. Under these circumstances, too, there 
is some difficulty in distinguishing the former disease - from enlarged 
liver, and from malignant disease of the lung or pleura. 

The causes of pleurisy are — 

1. Exposure to cold. This is perhaps the most common, if not the 
alone, cause of pleurisy as a primary affection. Even when thus pro- 
duced, however, it is very often associated with pneumonia ; the dis- 
eases under such circumstances are not to be regarded as cause and 
effect, but as the joint effects of a common cause. 

2. It may arise from disorders of remote organs, as when disease 
of the liver or kidneys, but especially the latter, impedes the depura- 
tion of the blood by those organs, in which case, as we shall have 
further occasion to observe, inflammation is very apt to arise sud- 
denly in some serous membrance ; again, cases of pleurisy sometimes 
occur which depend on the presence of suppuration in other parts of 
the body, and also in specific inflammations of the skin, as erysipelas ; 
these are of a peculiarly dangerous and intractable character. 

The presence of other morbid poisons in the system may also 
excite inflammation of the pleura, as well as of other serous mem- 
branes ; of this we have a familiar instance in the frequency and 
intensity of pleuritis occurring in influenza. 

Pleurisy may also be excited by extension of disease in a neigh- 
bouring organ, the most common instance of which is, the inflamma- 
tion of a part of this membrane covering a tuberculous portion of 
lung ; it is also set up over a diseased rib ; and sometimes, though 
not so frequently, by extension of disease below the diaphragm, as 
when intense inflammation occurs in the peritoneal covering of the 
latter. The same thing likewise happens occasionally in inflamma- 
tion of the pericardium. Pleurisy may also be the effect of mechanical 
injury, as of the splintered ends of a fractured rib ; and sometimes of 
a severe blow, independently of any such fracture. 

The admission of air into the cavity of the pleura will almost 
always, though perhaps not universally, excite inflammation of 
that membrane ; and thus it may be induced not only by accidental 
injuries, or surgical operations, in which the air enters from without, 
but also by the extension of disease in the lung to the surface, in 
which case the air enters from within. In this way, a tuberculous 
cavity may, by opening into the pleura, establish a communication 
between a bronchial tube and the cavity of that membrane. It 
ordinarily happens, that, as the inflammation extends towards the 



216 PLEUEITIS. 

surface of the lung, the pleura covering it becomes inflamed, and this 
inflammation, extending by contiguity to the costal pleura in appo- 
sition to the part, adhesion ensues, and thus the escape either of air 
or matter is stopped, and the great extension of the pleuritis is pre- 
vented. Sometimes, nevertheless, the ulceration reaches the pleura 
without any such adhesion, and the consequence is an escape of air, 
and perhaps matter, into the cavity. A pulmonary vesicle, distended 
by emphysema of the lung, and lying immediately below the pleura, 
may give way during some strong exertion, and thus an escape of 
air takes place into the pleura. In almost, if not entirely, all cases in 
which air thus finds it way into the pleural cavity, inflammation of 
the membrane* ensues, and the product of such inflammation is almost 
certainly puriform. Instances sometimes occur indeed, in which, 
from the latter of the causes mentioned, namely, the sudden giving 
way of a dilated vesicle, there appears to be very little, if any inflam- 
mation or effusion in the pleura for a considerable time. There is, 
again, another way in which a communication may arise between the 
pleura and the bronchi, and that is, when a circumscribed pleuritic 
effusion ulcerates through the pleura pulmonalis; though its taking 
this course is far less common than its making its way through the 
intercostal spaces. 

The presence of air in the pleura has been designated by the term 
pneumothorax ; when, however, as generally happens, there is like- 
wise fluid in the cavity, it is termed pneumothorax with effusion, and 
sometimes empyema with pneumothorax, or hyclro-pneumothorax, 
which last term, however, is objectionable. 

The invasion and presence of pneumothorax are characterised 
by remarkable symptoms, with which it is very necessary to be 
acquainted, and which are the result of the sudden admission of air 
between the two surfaces of the pleura, of the more or less rapid 
collapse of the lung, consequent upon it, and of the inflammation of 
greater or less intensity, which nearly always attends it. We here 
speak more especially of those cases in which the pneumothorax is 
the result of admission of air through the lungs, since, in those cases 
in which it finds its way from without, the nature of the wound or 
operation renders the disease sufficiently obvious. "When a pneumo- 
thorax is caused by perforation of the pleura from a vomical cavity, 
there will most commonly have been previous signs of phthisis, 
though not necessarily far advanced : the patient is suddenly seized 
with intense lancinating pain in the side, urgent dyspnoea, and fre- 
quently a great depression of the heart's action, threatening death 
from syncope, which sometimes actually ensues. It most commonly 
happens, however, that after a time reaction takes place, and there 
are the symptoms of severe pleuritis, though generally with con- 
siderable depression of the vital powers, the pulse being small and 
wiry; the patient breathes laboriously; generally reclines in a semi- 
recumbent attitude, with the shoulders raised, not turning, most 
commonly, entirely to either side, but assuming a sort of diagonal 
position, and supporting himself as it were upon the scapula; the 
side towards which he turns being either the sound or affected side, 



PNEUMOTHORAX. 217 

according to circumstances: most commonly, however, it is the 
affected side. At the first escape, indeed, of the air into the pleural 
cavity, the quantity of matter which accompanies it being for the 
mostfpart small ; the pressure of the sound lung, as well as the heart, 
when the pneumothorax is on the right side, upon the mediastinum 
stretched over an empty cavity, might be supposed to cause some 
inconvenience, though this is very doubtful ; but after a time, when 
the fluid has increased, there is far more inconvenience felt by the 
pressure of that fluid, or by its gravitating, through the opening in 
the lung into the trachea; and the patient then lies on the affected 
side. The d}^spnoea almost always continues, in a greater or less 
degree ; and when the quantity of air, or the subsequent effusion is 
very great, there will also be displacement of the heart, as in hydro- 
thorax ; sometimes also there is protrusion of the intercostal spaces. 

The air, of course, escapes into the cavity, with greater or less 
rapidity, according to the size of the opening; and the distending 
force of the air in the lung being counterbalanced by that between 
it and the walls of the chest, the lung collapses by its natural elas- 
ticity, and, when not prevented by adhesions, is compressed into a 
small space against the vertebrae and mediastinum. Sometimes the 
opening in the pleura is valvular; and the air, entering the pleura at 
each inspiration, is unable to escape, owing to the closure of the valve 
by the greater pressure exerted upon the inner surface when the ribs 
descend in expiration ; and the result is an enormous accumulation 
of air in the pleura, threatening suffocation; which, if it be not 
allowed to escape, sometimes ensues. It occasionally happens that a 
person subject to emphysema of the lung, is suddenly seized with 
urgent dyspnoea during exertion, or in a fit of coughing ; this is fol- 
lowed by signs of pleurisy, not commonly of equal severity with 
those in the former case : here a dilated vesicle has given way, and 
allowed the escape of air into the pleural cavity ; the same thing may 
also be brought about in gangrene, or sloughing of the lung. In the 
case in which an opening is made from the pleura into the lung, by 
an accumulation of pus in the former making its way into a bron- 
chial tube, the collapse of the lung will generally be prevented by 
the surrounding adhesion, and the dyspnoea will rarely be urgent, 
unless the quantity of matter be so great as to be incapable of being 
expectorated with sufficient rapidity to prevent a considerable por- 
tion regurgitating through the tubes into the rest of the lung. These 
cases too are characterised from the first by a copious discharge of 
pus, which soon becomes foetid. 

The physical signs of pneumothorax are highly characteristic, pre- 
cisely, in fact, what might be expected from one side of the chest 
containing air with some liquid, and the lung being collapsed. 
"When the affected side of the chest is percussed, it emits, over a 
considerable extent, a sound far exceeding in resonance that o^ the 
same region when filled with ordinary inflated lung, and more resem- 
bling the drum-like sound of a flatulent stomach, at the same time 
that the natural sounds of respiration are perfectly silenced; thus 
presenting a contrast to the opposite side, where the resonance is 



218 PLEURITIS. 

somewhat diminished, and the respiratory sounds increased. When, 
however, the patient speaks or coughs, there will be heard a remark- 
able ringing metallic sound, which, from its resemblance to the ringing 
of a nearly empty cask, has been termed amphoric, and which may 
be imitated by applying a child's india-rubber ball to the ear and 
gently striking it. A similar sound may be elicited by gently tap- 
ping a chest in this condition, provided it be not done too near the 
part where the stethoscope is applied. These sounds receive a strik- 
ing addition from the presence of fluid, the least agitation of which, 
from the movements of the patient, give a tinkling sound, the tinte- 
ment metallique of French authors. The fluid, of course, occupies the 
lower portion of the chest, and the air the upper, and, therefore, when 
the patient sits upright, the upper portion of the chest will be reso- 
nant, and the lower perfectly dull; the depth of the non-resonant 
portion depending upon the quantity of the fluid. The metallic 
sounds will generally be best heard a little below the nipple, and at 
the base of the scapula ; and the relative situations of the dulness, 
and excessive resonance, may be changed by altering the position of 
the patient, just as in a barrel half full of liquid. Another remark- 
able sign is obtained by placing the patient in an erect position, and 
giving him a shake rather sharply, when a splashing sound may be 
heard, which can be compared to nothing better than the sound of 
shaking water in a barrel. 

It may be as well here to remark, that the condition necessary for 
these amphoric or metallic sounds, is a large hollow, containg air and 
liquid; and that a communication between the external air and this 
cavity are not so ; and, therefore, we may have those metallic sounds 
should that opening become plugged up; and, in the hypothetical 
cases of air being secreted by the pleura, or of a cavity formed by the 
absorption of effused fluid more rapidly than the walls of the chest 
could collapse or the lung expand to close the vacuum, we should 
still have these metallic sounds ; and the same sounds may often be 
heard over the stomach, and in that situation have actually been mis- 
taken, by experienced auscultators, for those of a pneumothorax, in 
a case where there was at the same time extensive pleuritic effusion. 
But when there exists a fistulous opening between the lung and the 
pleura, which is most commonly the case in pneumothorax, or when 
it continues unclosed, we have the additional sound of an amphoric 
voice and respiration, resembling that which might be produced by 
blowing into the mouth of a bottle. 

The prognosis of pleurisy is generally favourable in the early 
stages, but must be modified, in a great measure, by the extent of 
the disease and the constitution of the subject ; it is rarely, if ever, 
fatal before the effusion of any inflammatory product has taken place ; 
but if a large surface of the membrane be suddenly affected, or if 
both pleurae become inflamed at the same time, especially that portion 
which covers the diaphragm, the inflammation exerts a remarkably 
depressing effect on the heart's action, the pulse becoming feeble and 
contracted, and death from syncope may ensue in the stage of plastic 
effusion. It most frequently happens, however, that the inflamma- 



PROGNOSIS. 219 

tion yields to ordinary remedies, but permanent adhesion is the 
result; so common indeed, is this, that in the majority of persons, 
some portion of the pleura is found adherent after death. When, 
however, the layer of plastic lymph causing the adhesion has been 
of considerable thickness, there will be some contraction, producing 
often more or less deformity. These adhesions are a very frequent 
cause of pleurodynia. 

When there is a considerable amount of serum effused, producing 
compression of the lung, in the manner already described, the pro- 
spect of recovery will depend much upon the quantity and character 
of the former : when it is not very great in quantity, nor of a puri- 
form character, its resorption may pretty confidently be expected; 
but, if the quantity be very great, which may be ascertained from 
the signs already stated, there is danger of suffocation from the rapid 
compression of the lung : if this do not take place, the absorption of 
the fluid will probably be very slow, and if it be of a puriform cha- 
racter, which may generally be suspected from the occurrence of 
chills, followed by flushings of heat, the danger of suffocation will be 
still greater ; or the fluid may assume still more the character of pus, 
and degenerate into chronic empyema, which may empty itself either 
through the lung or the wall of the chest, or may continue a source 
of constitutional irritation ; and, in either case, there is much reason 
to apprehend that the patient will sink under hectic. Such, then, 
being the modes of fatal termination of pleurisy, it is evident that 
where the disease attacks both sides of the chest, or where the effu- 
sion takes place very rapidly, and to a great extent, our prognosis 
must be very guarded, if not unfavourable, and the danger must be 
considered as still greater when there is the slightest appearance of 
hectic. 

In any individual case, a subsidence of the fever, and correspond- 
ing relief of the pain and dyspnoea, with the absence of all symptoms 
of increasing effusion, are to be considered as favourable omens. 
Whilst aggravation of the pain, increased difficulty of breathing, and 
still accumulating effusion, especially if the pulse become rapid and 
feeble, whilst there is an appearance of lividity in the countenance, 
are indicative of most imminent danger; and in double pleurisy 
about the diaphragm, even if there be little or no liquid effusion, 
any sign of the failure of the heart's action must be viewed with the 
greatest apprehension. 

It has been already stated that inflammation of the pleura may be 
excited by morbid poisons, as in the case of influenza or eruptive 
fever, and may arise from non-depuration of the blood, as in disease 
of the liver and kidneys, especially of the latter. In these cases the 
prognosis is more unfavourable, and must depend principally upon 
the character of the primary disease. There are also, undoubtedly, 
instances of pleurisy (as observed by Dr. Alison) of peculiar fatality, 
and little influenced by treatment, which depend upon the presence 
of suppuration in other parts of the body, and of puriform matter in 
the circulation ; in both these the effusion is puriform probably from 
the commencement ; and there are cases, seen chiefly in hospitals, in 



220 PLEURITIS. 

convalescents from febrile diseases, and especially from small-pox, 
which would seem to be of the same specific and peculiarly intracta- 
ble character. Pleurisy, arising from perforation of the pleura pul- 
monalis, is almost always fatal, though the time which a patient 
may survive is much longer than used generally to be supposed. 
Andral states that death almost certainly takes place within a few 
days ; this, however, is at variance with the experience of British 
practitioners, as many cases are on record, in which life has been 
protracted for a considerable time ; instances of this kind are men- 
tioned by Dr. Watson; one is related by Dr. Houghton, in which 
the patient survived thirteen months ; and one occurred to the author 
of this work, in which the patient lived three years after the estab- 
lishment of a fistulous communication between the lung and the 
pleura."* It is moreover remarkable how little distress is occasioned 
by this state of things, persons having been known often to take 
active exercise, and even to hunt without complaining of any incon- 
venience beyond the annoyance of the splashing of the fluid in the 
chest. In childhood and early youth, however, the prognosis of 
pneumothorax with effusion, though certainly unfavourable, is not 
so desperate as in persons more advanced in life. A patient of the 
author's, a lad ten years old, was the subject of a pneumothorax, 
with abundant foetid puriform effusion into the left pleura. Suffoca- 
tion impending, the fluid was let out by a puncture between the ribs, 
the patient slowly but steadily regaining flesh, and losing the dysp- 
noea, and after some months, the left lung was perfectly inflated, 
though by what means nature closed, in the pulmonic pleura, the 
orifice is not very apparent. 

The treatment of simple pleurisy in its early stages, and in patients 
of tolerably good constitution, should be decidedly antiphlogistic. It 
has been already observed, that bleeding is better borne in inflamma- 
tions of serous membranes than of almost any other tissue of the 
body. "When, therefore, a patient is seen while the stitch is severe, 
the tongue furred, the pulse sharp, and before there is any consider- 
able amount of effusion, it will generally be not only safe, but highly 
expedient, to bleed him, in an erect posture, to a pint, or to the first 
signs of fainting ; and this may sometimes be repeated with advan- 
tage within twelve hours ; and it is to be remembered that the bleed- 
ing so timed, tells more upon the inflammation, and less upon the 
strength of the patient, than at a later period of the disease. Even 
here, however, it is necessary that what has been stated, respecting 
the depressing influence of acute inflammation in the neighbourhood 
of the diaphragm, should not be forgotten, and, therefore, in such 
cases, when the pulse is wiry, the effects of loss of blood should be 
carefully watched, and the vein closed upon the slightest approach of 
syncope, and if the pulse do not increase in volume, after the first 
bleeding, a second should on no account be ventured upon. When 
the state of the pulse or the constitution of the patient is such as not 
to warrant general bleeding, from twelve to twenty leeches may be 

* Vide Guy's Hospital Reports, vol. iv. p. 339. 



TREATMENT. 221 

applied to the side ; or, what is still better, blood may be taken from 
the same part by cupping, to the amount of ten or twelve ounces ; 
and even in cases where there is very considerable depression, cup- 
ping to a small amount is very beneficial, as much perhaps from the 
revulsive effects of the glasses, as from the actual abstraction of the 
blood. The combination of tartar-emetic, calomel, and opium, which 
has been already recommended, will here also be highly beneficial; 
indeed if the inflammation be not at once arrested by the bleeding, 
the disease will rarely be subdued until some effect has been pro- 
duced upon the mouth by the mercury. For this purpose it will be 
well to give from two to four grains of the calomel with half a grain 
of opium and one-fourth of a grain of the tartar emetic ; the latter of 
these medicines has not indeed the same powerful effect in this dis- 
ease as in inflammations of some other structures, but thus given it 
is a useful adjunct. The opium is serviceable as a sedative, and in 
preventing the mercury from running off by the bowels ; and should 
there be any tendency to diarrhoea, it may be increased to as much, 
as a grain. When the pain is in some degree subdued, the skin cool 
and moist, and the pulse softened, the application of a blister to the 
side will greatly accelerate the cure. 

Sometimes, however, notwithstanding the use of these means, the 
difficulty of breathing and of lying down is increased, although the 
pain and fever may have subsided, and we have unmistakable signs 
of accumulation of fluid in the pleura, namely, dulness, broncho- 
phony, and, perhaps, bulging of the ribs : and the removal of this 
fluid will often be a work of considerable difficulty. To promote 
this, the patient should be kept on as low diet as his strength will 
justify ; a slight mercurial action should be maintained, blisters re- 
peatedly applied to the side, and diuretics administered. The best 
form of mercurial in this condition of the patient, is the combination 
of the blue pill, or, what is still better, the grey oxide of mercury, 
with compound squill pill, which, while it maintains ' the mercurial 
action, aids that of other diuretics. As regards the effect of the 
latter remedies, there is at all times considerable uncertainty, which 
is mainly to be attributed to the condition of the other viscera ; yet, 
as recent inflammatory effusion into the pleura does not necessarily 
imply previous disease, either of the heart, lungs, liver, or kidneys, 
we shall commonly succeed in obtaining a free action by a judicious 
combination of diuretic medicines. Saline diuretics, as nitrate or 
acetate of potass, in combination with infusion of digitalis, and nitric 
ether, will often succeed, the latter medicine rendering the action of 
the digitalis much more certain and more safe. The infusion of the 
digitalis is to be preferred, as being the most diuretic form for its 
exhibition, and being the least likely dangerously to depress the 
action of the heart. Should these remedies fail in their effect, or 
should they appear too much to reduce the strength of the patient, 
the iodide of potassium may be substituted for a time ; purgatives 
should be at the same time freely employed, of which the compound 
jalap powder is generally to be preferred. 

By perseverance in this plan of treatment, the absorption of the 



222 DIURETICS. 

fluid may often be brought about, and the lung restored to its healthy- 
state. Sometimes even after the fluid has been absorbed, the affected 
side does not return to its natural condition, but becomes contracted 
or shrunk, owing in this case to the lung, which has been tied down 
by adhesions, not expanding to meet the ribs as the fluid diminishes ; 
whilst the consequent pressure of the atmosphere, often, no doubt, 
aided by the contraction of the false membrane, thrown out upon the 
costal pleura, compresses the ribs inwards towards the mediastinum. 
It has been supposed, indeed, by some, that the fluid absorbed under 
these circumstances is replaced by a secretion of air from the pleura, 
thus giving rise to a pneumothorax; but this is very doubtful. In 
most cases of this kind, the lung never fully expands again, and the 
flattening of the chest, and the curvature of the spine which gene- 
rally attend it, remain for life, though this is not attended with any 
serious inconvenience, beyond the deformity, except in the cases of 
young persons whose growth is not complete, in whom, as we shall 
hereafter explain, everything which diminishes the capacity of the 
chest is a serious evil. In such persons, however, there is reason to 
believe that the configuration of the chest may sometimes be in a 
great measure, if not entirely, restored: the same thing sometimes 
happens where the effusion has been almost entirely plastic lymph, 
but little serum having been poured out. In this case, after the pain 
and fever have subsided, the shrinking sometimes continues, and the 
side remains dull on percussion, owing to the thickness of the new 
membrane, and to its impeding the vibration of the ribs. Besides 
the deformity, this new membrane is sometimes an additional source 
of mischief, since it may itself become the seat of fresh disease, as by 
going into suppuration, or becoming a nidus for tubercles. 

If after the means which have been recommended for bringing 
about the absorption of fluid in the pleura have been persever- 
ingly used, there is no apparent diminution in its quantity, or if 
it should suddenly increase so as to threaten to destroy the patient 
by suffocation, the important question arises, as to whether it should 
be got rid of by making an opening into the pleura, that is to say, by 
tapping the chest. Although this operation is neither difficult nor, 
generally speaking, immediately dangerous, it may be well here to 
protest against its indiscriminate or too early employment, not only 
on account of the danger of admitting air into the pleura, which 
would, according to the principles already laid down, convert a 
serous effusion into a puriform fluid, but also because experience has 
taught us that, independently of such an accident, its repetition 
would produce the same result, and we have already seen that in 
the majority of cases such an effusion may be got rid of by other 
means. In short, the objections to the operation may be thus 
summed up, — where it is safe and likely to be successful, it is unne- 
cessary, but where it seems to be called for by the permanence of 
the effusion, it is more dangerous, and generally unsuccessful. 

As long then as we believe the fluid to be serum, the operation 
ought not to be had recourse to, except to avert impending suffoca- 
tion. It is true, indeed, that eclat often results to the practitioner 



PARACENTESIS. 223 

from its performance, but it is no less true that in the majority of 
instances the safety of the patient is compromised. When, however, 
we know, no matter by what means, that there is a large quantity 
of pus in the cavity of the pleura, the reasons in favor of its with- 
drawal are apparently stronger ; nevertheless it may well be doubted, 
whether the results of experience will show that it has more fre- 
quently been productive of good than harm ; for, though it is con- 
tended by many that pus cannot be wholly absorbed, yet the familiar 
instance of hypopion proves that it may be, in a great measure, if 
not entirely; and there is every reason to believe that in the cases 
under consideration, the serous part of the pus may be removed by 
absorption, leaving the pus globules in the form of a cheesy mass, 
which produces no serious inconvenience; and where this is not the 
case, the process adopted by nature, of finding an exit for the matter 
by slow absorption, going on in one of the intercostal spaces, and 
causing a pointing externally, will generally be found to give more 
safe and certain relief than the apparently more expeditious, but pos- 
sibly premature, interference of the surgeon. It is, however, but 
fair to admit, that there is considerable difference of opinion on this 
subject, and that some writers of deservedly high authority recom- 
mend the withdrawal of pus whenever it is known to exist in the pleura. 

When the urgency of the case calls for the performance of the 
operation, the next thing to be determined is, where the operation is 
to be performed. Now it seems superfluous to say, " be careful not 
to tap the wrong side of the chest;" yet such a thing has happened, 
and the respirable lung having collapsed from the admission of air 
into the chest, the result was, as may be expected, the instant death 
of the patient. A blunder of this kind, arising from ignorance as to 
which pleura is the seat of the effusion, would be little less than 
criminal with our present means of diagnosis. The best point to 
select in the side will generally be between the angles of the sixth 
and seventh rib, but here, before proceeding to introduce a trochar, 
it will be well to place the presence of the fluid beyond a doubt by 
the introduction of the grooved exploring needle of Dr. Davis, or 
what is still better the small exploring trochar and canula first used 
by Dr. Babington, which has the advantage, not only of deciding 
upon the presence of fluid, and its serous or puriform character, as 
well and as safely as the needle, but also of admitting the introduc- 
tion of a small silver probe, by which the distance between the lung 
and the ribs may be ascertained, and the quantity of the fluid, as 
well as the presence or absence of adhesions, inferred. 

When the fluid that flows through the canula is serum, it will be best 
to allow it to run as long as it will continue to do so without the admis- 
sion of air into the chest, and then the orifice should be closed; but 
when it is puriform, the fluid may be allowed to run as long as any 
can be obtained, and the orifice may be left open. For some excel- 
lent directions as to the best mode of performing the operation, as 
well as valuable suggestions respecting the diagnosis of empyema, 
the reader is recommended to consult an able article by Dr. Hughes 
and Mr. Edward Cook, in the Guy's Hospital Reports, Second Scries. 
vol. ii. pp. 48, et seq. 



224 BRONCHO-PNEUMONIA. 

Whatever opinion we may form as to the expediency of tapping 
the chest — and it is not to be concealed that many physicians enter- 
tain opinions far more favourable to it than those expressed above, 
— there are objections to it in cases where the pleuritis is complicated 
with extensive consolidation, which appear to us to be of peculiar 
force, though we are not aware of these being stated by any previous 
writer; but before entering into them, we proceed to make a few 
remarks upon the complications of pleurisy, pneumonia, and bron- 
chitis with each other. 

In treating of pneumonia, we alluded to the frequent coexistence 
of bronchitis ; now it is needless to do more than repeat this to make 
it apparent, that a large number — the larger number — of cases of 
pneumonia, which we meet with in practice, must present symptoms 
different from those which have been described as belonsriuo* to 
pneumonia simply as such. If, however, the above fact be borne in 
mind, the bronchitic complication need not embarrass us much ; since 
the symptoms are such as might be expected from the coexistence of 
the two diseases. The rattle may -indeed mask the bronchitic crepi- 
tation, as the rattles and ronchus in the larger tubes were stated to 
have obscured those in the smaller ; but generally there will be crepi- 
tation to be heard over a greater or less extent, and, if the pneumonia 
proceed, the occurrence of dulness on percussion will at once decide 
the matter. The expectoration will often be of a mixed character, 
being more fluid than that of simple pneumonia, but possessing a 
degree of viscidity that does not belong to the sputa of uncompli- 
cated bronchitis. The constitutional symptoms again will be of an 
intermediate character ; the skin will always at some period present 
the characteristic pungent heat of pneumonia ; but this mil not be of 
so long duration, and even while it lasts there will be a tendency to 
coolness, or even moisture, about the extremities. The pulse again 
will be softer, and the tongue redder at the edges. 

As regards the prognosis of the disease, it must be regulated upon 
the principles already laid down in treating of each of these diseases 
singly ; but in the expectation of perfect and permanent recovery we 
must not overlook the effect of pneumonic consolidation in promoting 
dilatation of the bronchial tubes; the contraction of the fibrinous 
effusion constituting the consolidation, by drawing the walls of the 
tubes asunder, aids the other causes which have been mentioned 
(182) in producing that lesion. 

The treatment of this complication must be regarded upon the 
same principles ; if what has been stated respecting the indications 
for bleeding in pneumonia be applied to the case in point, the exist- 
ence of this affection will not lead to its adoption merely upon the 
grounds of the presence of pneumonia, though the existence of bron- 
chitis should always act as a caution to dissuade from its too ready 
adoption, unless the indications are very decided. 

Closely connected with the complication of pneumonia with bron- 
chitis is the peripneumonia notha, or catarrhus senilis of the older 
authors. These cases are in fact little more than instances of asthe- 
nic bronchitis occurring in persons generally advanced in life, who 



PERIPNEUMONIA NOTHA. 225 

have been subject to long continued congestion of the lungs, the 
consequence either of repeated bronchitis or disease of the heart ; but, 
besides this, the inflammation in the smaller tubes is very apt to 
extend &> the air-cells, and pneumonia of an adynamic type is rapidly 
or almoJfe suddenly excited. The symptoms of the disease are gene- 
rally those of severe and extensive bronchitis, threatening death, 
sometimes from apnoea, at others from asthenia, either from the 
depressing effects of the inflammation upon a feeble constitution, or 
from the exhaustion consequent upon a profuse puriform secretion. 
It not uncommonly happens, however, that there is great relief from 
a copious expectoration. 

The pulse is commonly feeble, though it may appear hard from 
the condition of artery so common in advanced life. The tongue is 
red at the edges, but coated in the centre, and soon evinces a ten- 
dency to become brown and dry ; the skin is often hot, especially 
over the surface of the trunk, though the extremities will soon 
become cool and clammy. 

Dr. Watson remarks that the nicety of treatment required in cer- 
tain stages of acute bronchitis is still more apparent and necessary 
here. But it may well be doubted whether we are often called upon 
to take blood in any way, though the assumption, from the age of 
the patient, that the disease is peripneumonia notha, and not acute 
bronchitis, ought not to deter us from moderate antiphlogistic meas- 
ures, when called for by the symptoms and powers of the patient. 
At the same time we must be very cautious not to mistake the hard 
artery (p. 70), for a hard pulse, and be misled by it into the belief 
that the patient can bear bleeding. 

The treatment, then, must be that of bronchitis, with the anticipa- 
tion of a failing of the constitutional powers. The liquor amnion, 
acet. with a little vinum ipecac, may be used at the commencement, 
and ammonia added in excess, when signs of debility appear. When 
the skin becomes perspirable a blister may be applied to the chest. 
The intercurrence of pneumonia rarely calls for active antiphlogistic 
measures, and should the sputa assume the " plum-juice" appearance, 
it is rather an additional reason for support, or even stimulants. 
The combination of senega with ammonia and squills (F. 25) is often 
of the greatest service in the advanced stages of peripneumonia notha. 

In the scarcely less common complication of pneumonia with pleu- 
ritis, generally known as pleuro-peripneumony or pleura-pneumonia, 
there will be a blending of symptoms, which, however, will not 
mask them so as to occasion any real difficulty ; neither is there any 
reason for supposing that the complication increases the danger. 
When large effusion takes place, the stethoscopic signs of the pneu- 
monia will be, in a great measure, silenced by the compression of the 
lung ; but in the commencement, the crepitation may generally be 
distinctly heard; and after slight effusion, it may sometimes be 
detected above the bronchophony, or above the line of dulness. 

The treatment of pleuro-pneumonia, must, in general, be conducted 
upon the same principles as those laid down for pneumonia and pleii- 
ritis. There is, however, a form of complication which is worthy a 

15 



226 BKONCHO-PLEURO-PNEUMONIA. 

short consideration, and that is the coexistence of extensive bronchi- 
tis, pneumonia, and pleuritic effusion in the same side of the chest 
"When this takes place, the lung will not collapse so readily as wher 
it has been unaffected, and universal dulness of that side will b« 
caused by a less amount of effusion than would have been otherwise 
necessary to produce the same effect, the anatomical condition bein£ 
an uncollapsed, because consolidated, lung, surrounded by serous oi 
sero-puriform effusion, the bronchial tubes being also more or less 
inflamed. But though the lung is, from the change in its physica 
condition, not susceptible of being collapsed, it is nevertheless com 
pressed sufficiently to arrest the progress of the disease, or, at al 
events, to retard it, so that the effusion may be looked upon, as, to i 
certain extent, conservative. 

Suppose now that the ' effusion were suddenly withdrawn — the 
consequences would be that the inflammatory changes would agaii 
proceed, and, if the subject were one of feeble constitutional powei 
(and it is in such that we most commonly meet with the above con 
dition), it is highly probable that disorganisation would be the re 
suit, and the patient sink under its exhausting effects. If, however 
the fluid were to be slowly removed, we might expect that the lung 
would either return to the healthy condition, or go into the state ol 
permanent induration ; in which case the contraction of the pulmo 
nary tissue would draw asunder the walls of the bronchial tubes 
But as bronchitis already exists, it is probable that as the lung 
begins to be again inflated, it will resume its activity, and a consider 
able puriform secretion will ensue, which will tend to increase th( 
distension which sometimes becomes so grea,t that the sounds o: 
cavities are produced in the tubes. 

From this we would infer, that, under such circumstances, it woulc 
be highly inexpedient to draw off the fluid, and further, that wher 
such cases go on favourably, the progress would be, considerable 
puriform expectoration, contemporaneously with the diminution ol 
the fluid ; the first signs of respiration to be detected in the lung 
being of a cavernous character, resembling those heard in vomicae, 
though sometimes these pseudo-cavities may be so large as to simu 
late amphoric sounds. Such cases do not uncommonly occur, anc 
the pre-existence of pleuritic effusion, the subsequent copious puri 
form expectoration, aud the cavernous or even amphoric sounds 
have led to the belief that there had been perforation of the pleura 
and that the patient was bringing up the contents of an empyema 
with pneumothorax. They may, however, be accurately distin 
guished from the latter, by the previous history, — by the stethosco 
pic signs during the effusion, since (though there is universal dulness 
and absence of respiratory sound) bronchial breathing and bronchia] 
voice, though distant, may still be heard, which they would not hi 
in cases of perfect compression of the lung, — by the absence of any 
history of a sudden perforation, and lastly, — by the nummulai 
character of the sputa. 

These cases will often do well with the treatment recommended 
for that of pneumonia in the state of grey hepatisation, with diur- 
etics, repeated blisters, and good nourishment. 



PHTHISIS. 227 



XIII. 
PHTHISIS. 

The word phthisis is derived from the Greek verb $0ivu> (corrumpo) 
and therefore strictly means a wasting disease. It has, however, 
been generally used in medicine, and that from the earliest times, to 
signify a wasting dependent upon disorganising disease of the lungs ; 
and the term has been still further restricted by most modern patho- 
logists to those cases only in which this disorganisation is the result 
of tuberculous deposit. It will, however, be more convenient as 
well as more in accordance with what has been already stated in 
speaking of the effects of inflammation and of scrofulous and tuber- 
culous deposits, to include under the term phthisis all those cases in 
which there is strumous deposit in the lungs, although it may not be 
of that character which strictly belongs to what we have already 
described as tubercle : the course and symptoms of the disease are, 
however, in either case so nearly the same, that, for practical pur- 
poses, the distinction is perhaps rather nominal than real. 

As pulmonary phthisis is one of those diseases, the chief symptoms 
and fatal termination of which are dependent upon a series of morbid 
changes effected in certain organs, we first describe those changes 
and afterwards the symptoms resulting therefrom. These changes 
are, in fact, precisely those which have been described as brought 
about by tuberculous deposits in general. These are at first the 
small grey semi-transparent tubercles of the size of millet-seeds, or 
the larger crude yellow tubercles (p. 107) deposited in clusters in the 
lungs, the latter being often, though not necessarily, a more advanced 
stage of the former. These tubercles then begin to soften, with 
greater or less rapidity, as already pointed out (p. 108), involving in 
their disorganisation the portion of lung in which they have been 
deposited ; the product of which joint disorganisation is a thick, 
apparently puriform fluid, contained in a cavity often lined, like an 
abscess, by a layer of fibrinous matter ; or several of these clusters or 
centres of disorganisation running together enclose an isolated por- 
tion of comparatively healthy lung, and thus a larger cavity or 
vomica is formed. This disorganised mass generally makes its way 
by ulceration to the nearest mucous surface, i. e., a bronchial tube, 
and thus the contents of the cavity may be expelled. Fresh tuber- 
cles are in the mean time deposited in the neighboring parts of the 
lung, and in this way the greater part of the organ is destroyed. 

The tuberculous deposit, unless its seat is previously determined 
by some local irritation, as pneumonia, almost always commences in 
the apex of the lung ; and as the tubercles in this situation proceed 
soonest to enlargement, softening, suppuration, and expulsion, and as 
fresh deposits of the same matter are continually taking place, lower 
and lower down in the organ, and following the same course, we 



228 PHTHISIS. 

commonly find after death that the disorganisation is most perfect in 
the apex, as shown by cavities of varying size, but generally large ; 
whilst lower down we see cavities generally smaller or less close 
together than above, the intervening space consisting in great mea- 
sure of lung apparently in a state of pneumonic consolidation, more 
or less thickly studded with tubercles. Still nearer the base there 
may be the above condition of lung without cavities, and lowest of 
all, there will commonly be respirable lung, nearly or entirely free 
from tuberculous deposit. 

It is an important fact, and one bearing most closely upon the 
pathology of pulmonary phthisis, that with the traces of disorganisa- 
tion, such as have been described as taking place generally in any 
tissue which is the seat of tuberculous deposit, we almost always find 
evidence of inflammatory action of greater or less activity. The 
lung surrounding a cavity is almost always condensed and solid ; and 
the cavity itself, when the tubercles are first expelled, is soft and 
ragged on its inner surface. It afterwards either extends by the 
softening of other tubercles in the immediate neighbourhood, which 
form fresh vomica? that open it, so that an irregular, or, as it is some- 
times termed, multilocular cavity is produced ; or, if there are no 
tubercles very near, a layer of fibrinous matter is deposited, which 
becomes organised, forming a species of lining membrane to the 
cavity, the vessels of which sometimes pour out pus ; but at others 
the fresh membrane contracts as in ordinary inflammation, and the 
cavity cicatrises, as it were, and is ultimately obliterated, giving rise 
to a puckering of the pleura on the corresponding surface of the 
lung. 

When this happens, the disease is arrested in the particular part, 
and a cure would take place if there were no fresh deposits in other 
parts of the same or corresponding organ ; but this, unfortunately, is 
very rarely the case, for, on the contrary, fresh deposits of tuberculous 
matter are, in by far the greater number of instances, continually 
taking place, and in this manner the disease is incessantly advancing 
by the repeated deposition of tuberculous matter, and not, as in the 
case of many malignant growths, by the continual assimilation of the 
adjacent tissues to their own structure. 

We see, then, that the process of disorganisation of the lung in the 
ordinary progress of phthisis is in a manner twofold, for we have the 
deposition of the tuberculous matter enlarging and softening, and 
involving in this softening and disorganisation, the tissue in which 
it has been deposited, and besides this, another induration and subse- 
quent softening and ulceration, closely resembling, or rather identical 
with that which takes place in common inflammation. 

Here then we are met by two questions which have been much 
agitated, and which it is impossible altogether to evade, though a 
lengthened discussion of them would be foreign to the object of the 
present work : 1. What is the particular tissue of the lung in which 
the tuberculous deposits take place ? 2. Are they the product or the 
cause of the inflammatory action with which they are associated ? 

(1.) As regards the seat of the deposit, it is probable that the 



ITS CONNECTION WITH INFLAMMATION. 229 

opaque crude or yellow tubercle is deposited on, or rather in the 
lining membrane of the smaller tubes (as pointed out by Dr. Cars- 
well), and in the air-cells with which they communicate, thus giving 
rise to the little clusters of crude tubercles, like bunches of grapes, 
which may be often seen on making an incision into a phthisical 
lung ; whereas the grey semi-transparent tubercle is deposited in the 
cell, or in the cell wall, as in the case of the product of common in- 
flammation of the lung, and gives rise to the appearance commonly 
described as miliary tubercle. 

(2.) As regards the connexion of tubercle with inflammation, — 
although we have no proof that this deposit occurs as an immediate 
product of inflammation, yet there can be no doubt that the hyper - 
semia, or local determination of blood (p. 46) attendant upon inflam- 
mation may so greatly favour the deposition of tubercle, that it may 
in a number of instances, practically be regarded as its proximate 
cause, or, in the words of Dr. Alison, " Phthisis pulmonalis very 
frequently appears in practice as a consequence of inflammatory dis- 
eases ; usually of repeated attacks of them in their milder and more 
chronic form." This statement, which regards inflammation as the 
most prominent cause of that impaired nutrition of which tubercle 
may be the result, is not necessarily opposed to the belief that such 
derangement may arise independently of inflammation, and therefore 
we are willing to admit, in the words of the distinguished physician 
already quoted, that " phthisis sometimes shows itself and makes 
progress, chiefly in those most strongly predisposed, without any 
indications of inflammation preceding or attending it." There is, 
however, every reason to believe that such cases are very rare. 

It has been already stated, in treating of common inflammation, 
that we may have, as its products, inflammatory lymph or pus, the 
former of which, though capable of becoming organised and forming 
a permanent tissue, is nevertheless liable at any period of its progress 
to break down into the second, and in so doing to involve the tissue 
in which it has been deposited in the same process of disorganisation ; 
and also that, after it has become perfectly organised, this new tissue 
may become the seat of a fresh inflammation, which will generally 
be of a suppurative or disorganising character. Accordingly, as was 
specified in treating of pneumonia, the product of inflammation in 
the lung is, in sound subjects, almost always plastic, tending, if the 
inflammatory process be not arrested, to permanent induration of the 
organ ; but under unfavourable conditions, and in cachectic subjects, 
pus may be poured forth in the first instance (or corpuscular lymph 
which quickly becomes pus), or even if the product have been in the 
first instance of the plastic kind, it may, before it is completely orga- 
nised, break down into pus, involving (like tuberculous matter) the 
pulmonary tissue in which it has been deposited in a like disorganisa- 
tion ; and even when induration of the lung has actually taken place, 
and possibly when it has existed for months or even years, the part 
so affected may, under a fresh attack of inflammation, break down 
into suppuration, and form a cavity closely resembling one which 
has been formed by the softening down of the tuberculous deposit. 



230 VAKIETIES OF PHTHISIS. 

The above description includes the various forms of phthisical dis- 
organisation of the lung, which may be classed under three heads : 
1, The truly tuberculous, in which the deposition of tubercles takes 
place without being preceded, attended, or followed by pneumonia, 
and in which the disorganisation is the result of the softening down 
of the tuberculous matter, involving in its disorganisation the tissue 
in which it has been deposited ; 2, That in which inflammation, if it 
have not preceded and given rise to the formation of tubercles, arises 
in the course of their development, and is the main instrument by 
which the disorganisation of the lung is effected ; and 3, That in 
which the disorganisation of the lung and the formation of vomical 
cavities have their origin in pneumonia, and are brought about in- 
dependently of any true tuberculous deposit. So that we may have 
three classes of phthisis : (1), The tuberculous ; (2), The tuberculo- 
pneumonic ; and (3), The pneumonic. This classification of the 
varieties of phthisis was introduced by Dr. Addison, to whom also 
we are indebted for the description of the third or pneumonic variety. 
Of these varieties of phthisis, the first is very rarely, if ever, met with 
in practice in its perfect form, since inflammation, though it may not 
have originated the tubercles, is almost sure to affect some portion of 
the organ in the process of softening. Still, as this inflammation is 
rather an accident than essentially necessary, we cannot altogether 
disregard the theoretical possibility of the first variety. The second 
variety is by far the most common, and may be said to include 
nearly all the cases of phthisis in early life, occurring in subjects not 
previously injured by great exposure or intemperance. The third 
variety belongs more to the middle period of life, and it is probable 
that the greater number of cases of phthisis occuring near or after 
the age of forty are of this character. 

Phthisis is also divided by many authors into acute and chronic, 
as it sometimes runs an acute course, but much more frequently a 
chronic one. As therefore the latter may be considered the more 
typical form of the disease we shall speak first of it. 

Chronic phthisis has been commonly divided into three stages, 
depending upon the anatomical changes which take place in the lung, 
which stages are pretty well marked by certain physical signs, as 
those of deposition, softening, and ulceration or excavation. It is, 
however, worth the inquiry whether there be not another stage ante- 
cedent to the first of these, which might be termed the premonitory, 
since if such be found to exist, and if it can be recognised, or even 
conjectured by any appreciable signs, we may be enabled to apply 
our remedies at the time at which there is the greatest, or rather, the 
only, probability of their producing a satisfactory result. 

The stage of deposition, which is often regarded as the first, is that 
in which tubercles are first present in the lungs, and as they are 
generally considered as essential to phthisis, it may perhaps appear 
illogical to speak of any previous stage of the disease; but setting 
aside this dimcultv as rather formal than real, it must be obvious 
that since tubercle is itself a pathological epigenesis or morbid pro- 
duct, there must have been some antecedent diseased action, preced- 



ITS PREMONITORY STAGE. 231 

ing or even causing this product. This previous morbid condition 
is of a twofolc character, the one generally affecting the whole system, 
constituting what has been already described as the tuberculous dia- 
thesis, and the other local, depending often upon a determination of 
blood to the lungs, or r in other words, active congestion of those 
organs, a condition which is very likely to occur, as already pointed 
out, at the age when the general development of the system is com- 
pleted ; though it is not denied that in extreme cases of tuberculous 
diathesis tubercle may be deposited, as a simple perversion of nutri- 
tion, and without any appreciable amount of such congestion. 

In this first or premonitory stage of phthisis, the symptoms are not 
very marked, and we have often not very distinctive physical signs ; 
still there are often such symptoms preceding those of deposition. 
These signs are perhaps more of a general and physiological, than of 
a local and physical character, and are such as might be expected to 
arise from some embarrassment of the pulmonic circulation, in addi- 
tion to those of the tuberculous diathesis. Thus there will often be 
a fixed colour in the cheeks, with a very slight tendency to lividity 
there, as well as in the lips; the pulse will generally be quick and 
small, although the impulse of the heart may be considerable, owing 
to increased fulness of the right ventricle ; the hands and feet will 
often, from the same cause, be cooler than natural, with sometimes a 
slight clammy perspiration: the impeded circulation through the 
lungs will also affect that through the portal vessels, whence we 
have some signs of hepatic congestion, as dyspeptic symptoms, and 
scanty, and often turbid urine. The respiration, under such circum- 
stances, is generally quickened, though hardly in the same proportion 
as the pulse, and there is no dyspnoea so long as the patient remains 
quiet ; but the breathing becomes hurried and laborious upon very 
slight exertion, which also causes palpitation, owing to the blood, 
when hurried to the right side of the heart, not finding a free passage 
through the lungs. There is seldom much cough or expectoration 
in this stage of the disease. These symptoms, it may be observed, 
are merely those of obstructed pulmonic circulation, which might 
arise from several causes; but when observed about the time at 
which phthisis most commonly makes its appearance, they are suf- 
ficient to excite apprehension ; and if to these there be superadded 
expectoration of blood in any amount whatever, the grounds for 
apprehension will be still greater, and the chest should be carefully 
explored. 

Such examination will, at this stage, detect little or no diminution 
of the natural resonance of the chest; but when there is any it is 
under the clavicle or in the supra-spinous and clavicular regions, and 
more commonly on the left side than the right. There will as yet be 
no flattening of the ribs beneath the clavicles, but on the contrary, 
the affected side may be slightly more prominent than the other; 
neither is the mobility of the ribs at all impaired. Auscultation, 
again, declares little that is conclusive. The inspiratory murmur 
may be good over the whole of the lungs, but the expiratory is too 
distinctly audible under the clavicles. There may also be a fine 



232 PHTHISIS. 

mucous rattle in this situation, depending probably on tie congested 
condition of the bronchial membrane in the capillary tubes. The 
sounds of the heart will be natural over the surface of the organ, 
which surface, however, seems to occupy a greater soace than in 
health, owing to the fulness of the right ventricle: and, conse- 
quently, the precordial dulness will be increased; there will also 
sometimes be a soft systolic murmur, depending probably upon the 
same cause: the cardiac sounds are, however, at this stage of the 
disease more distinctly audible than in health in other parts of the 
chest ; and this is particularly the case over the apices of the lungs, 
and arises probably from the increased density of the lung rendering 
it a better conductor of sound than is the healthy organ, and which 
is the effect of the increased amount of blood in that condition which 
attends, or immediately precedes, the first deposition of tubercles. 
This state of the upper lobes of the lungs often gives rise to another 
phenomenon, which though not constantly present, or at least not 
always observed, is amongst the earliest premonitory signs of phthisis ; 
namely, a soft systolic murmur {bruit de soufflet) under the clavicles, 
generally heard about the situation of the bifurcation of the inno- 
minata on the right side, and of the subclavian on the left. It is not, 
however, so distinctly traceable over the course of the vessel as to be 
obviously produced by the current of blood through it, and it may 
be a question whether this murmur is really produced by the lung 
pressing upon the innominata or subclavian, or whether it be that 
the pulmonic circulation actually becomes audible owing to the 
increased vascularity and density of the lung, and thus a sound is 
produced analogous to the placental souffle. 

In the second stage of phthisis, that of deposition (the first stage of 
most authors), the symptoms, so called to distinguish them from the 
physical signs, begin more decidedly to manifest themselves. It 
should, however, be premised that, as has been correctly stated by 
Dr. Walshe, these symptoms do not admit of such systematic division, 
according to the stages of the disease, as do the physical signs. The 
cough is now almost always present — in a small proportion of cases, 
dry — but in far the greater number attended with a frothy expec- 
toration, or, what is a more unfavourable symptom, it may have a 
mucilaginous appearance. The sputa may also be streaked with 
blood, and even profuse haemoptysis is not uncommon at this period 
of the disease ; and it is perhaps from its frequently occurring at its 
very commencement, that an attack of hemoptysis has often been 
assigned as the cause of the subsequent phthisis ; though it is more 
correct to regard it as one of the accidents liable to occur in that 
disease, arising, at this period more especially, from the hyperaemia 
which exists in the lungs ; and although it is to be looked upon with 
apprehension as a precursor of impending mischief, it may be so far 
from a cause of that mischief, as to be a means employed by nature 
for its mitigation. 

Dyspnoea is not a more urgent symptom than in the premonitory 
stage ; indeed, in ordinary chronic phthisis, it is rarely so at all ; the 



ITS SECOND STAGE. 233 

respiration even upon moderate exertion, never being quickened 
more in proportion than the pulse, rarely so much so. 

Pain in the region of the chest, often of an acute, but seldom of a 
ve?y severe kind, is of common occurrence; these pains may be 
merely of a neuralgic character, but are more commonly the effect 
of partial pleurisies excited by the presence of clusters of tubercles, 
either on the serous membrane or immediately beneath it. 

Febrile symptoms are rarely well developed at this stage of the 
disease ; there is, however, during a great part of the day, an increased 
heat of the surface, excepting at the extremities, which are generally 
cold, often clammy, with a tendency to duskiness or lividity : at night, 
or rather during sleep, there will be an increased, but not an exces- 
sive perspiration, chiefly affecting the head and chest. The pulse is 
generally, though not invariably, frequent, small, and compressible ; 
it is in fact the pulse of pulmonic congestion (pp. 72 and 75), though 
it is, no doubt, accelerated likewise by the nervous irritability almost 
constantly attendant upon the tuberculosis diathesis. Exceptions to 
this rule no doubt occur, but they will generally be found in subjects 
in whom there has been some degree of dilatation of the left ventri- 
cle, or some other circumstance modifying the effect of the disturbed 
circulation through the lungs upon that of the system at large. There 
may, however, be great differences in the degree of acceleration, not 
only in different individuals, but in the same individual upon different, 
and even consecutive days. 

It has been stated that the difference between the pulse in the erect 
and recumbent postures, is less in the early stages of phthisis, than in 
other diseases attended with debility. 

The glandular system in the abdomen will rarely be perfectly 
healthy in persons of the tuberculous diathesis, and consequently its 
mucous surfaces will be prone to disorder; but in addition to this, it 
is to be observed that one of the first effects of pulmonic obstruction 
must be venous congestion of the liver, and consequently of the 
mucous membrane of the stomach and small intestines, uneasiness in 
the epigastrium, with tenderness below the ensiform cartilage as well 
as nausea ; irregular appetite and occasional vomiting are therefore of 
frequent occurrence, though the latter may sometimes be induced 
merely as the mechanical results of fits of coughing. Thirst is rarely 
absent at this or the subsequent periods of the disease. " 

The intellectual faculties are rarely much disturbed at this stage 
of phthisis, except in those cases in which there is also tuberculous 
deposit in the membranes of the brain, when active delirium may 
come on at any period. There is, however, in most cases, a good 
deal of nervous excitement, with restlessness, or irritability of temper. 

Emaciation, which is one of the most prominent features of this 
disease throughout its whole progress, is generally very apparent in 
this stage, and is greater than can fairly be accounted for by the 
vomiting or loss of appetite ; so much so, that it has generally been 
regarded as the direct and necessary consequences of the presence of 
tubercles, though it would perhaps be more correct to attribute it to 
that defect or perversion of nutrition of which the deposition of these 



234 PHTHISIS. 

bodies is one of the results ; though it is certain that in many cases in 
which their presence could not be questioned, not only have the 
patients ceased to lose flesh when the other symptoms of their pro- 
gress have been for a time arrested, but they have actually increased 
in weight. 

In the female the uterine functions are more or less disturbed in 
this as well as in the preceding period of the disease, it being by no 
means uncommon for menorrhagia to be the precursor of the invasion 
of phthisis; in some subjects, however, there will be a sudden sup- 
pression, which is always an unfavourable symptom, since in ordi- 
nary amenorrhcea or chlorosis there is generally a gradual diminution 
of the discharge for several successive periods ; neither is it uncom- 
mon for its sudden cessation to have been preceded by its excess. 

Upon examination of the chest, after the deposition of tubercles 
has commenced, there will generally be found a slight flattening of 
the infra-clavicular region of the more affected side. The mobility 
of the superior ribs, or, to speak more correctly, the expansion of the 
chest during inspiration is diminished ; these ribs being simply raised 
and not gently protruded as in health. The diminished expansion of 
the apex of the lung is a more important sign in the female than in 
the male, since in health this expansion is less in the latter than in 
the former. In some cases the expansive movement is altogether 
wanting, or there may even be an actual sinking of the infra-clavicu- 
lar regions during inspiration ; this is generally the effect of pleuritic 
adhesion. The tactile vibration of the voice, is in general absolutely 
increased in this region; but it should be remembered that it is in 
health greater on the right side than on the left, and in the male 
subject than in the female. 

There is generally, but not always, in this stage of the disease, 
diminished resonance on percussion. This may of course be almost 
invariably at first detected in the infra-clavicular region, and more 
frequently on the left side than on the right. It is most marked 
upon the inner side of this region immediately over the apex of 
the lung. At the commencement of tuberculisation, and when the 
tubercles may be supposed to be least thickly aggregated, the dimi- 
nution of the resonance may escape observation when percussion is 
made upon a single point, though it may be detected by percussing 
upon a larger surface. The increase in the resonance produced by a 
full inspiration, which is considerable in health, will be scarcely per- 
ceptible where tubercles exist in any considerable numbers. As the 
deposition and consolidation increase, the sound becomes duller, and 
so as to be even woody. This, however, indicates that there is at the 
same time agglutination of the surfaces of the pleura. The dulness 
on percussion is of course most obvious in the infra-clavicular and 
superior scapular regions, but as the deposition and its consequent 
changes extend, the dulness does so likewise. 

The respiratory sounds are in this stage considerably affected, 
being in some parts defective, in others increased, and in some 
tubular or bronchial. They are for the most part attended with 
mucous rattles; though these are rather to be regarded as one of the 



THIRD AND FOURTH STAGES. 235 

accidents than the necessary effects of the disease: and here and 
there about the parts where the signs of consolidation are most appa- 
rent, the dry crepitation from intercurrent pneumonia may not unfre- 
quently be heard. Perhaps the most important sign at this stage is 
harshness of respiration; though it is doubtful whether it do not 
belong more to the preceding, since there is good evidence for 
believing, and the same thing is affirmed pretty confidently by Dr. 
Stokes, that it may frequently be removed by treatment. 

In the third stage, or that of softening, the constitutional symptoms 
become more decidedly those of considerable suppuration, and we 
have generally confirmed hectic. There is now a remarkable bright- 
ness of the eyes, with pearly conjunctivae; the tongue is generally 
red towards the edges, and furred towards the centre; the bowels, 
too, are irregular, and apt to be disordered by slight causes, and it is 
probably in this stage that there commences that irritation of the 
lower part of the ileum and of the large intestines, which terminates 
in ulceration. The pulse continues frequent, or if it have not been 
so before, it now becomes so; the cough, which may have been 
but slight before, becomes troublesome, especially in the morning; 
and there is expectoration of puriform mucus, in which tubercular 
matter may sometimes be detected, and the voice assumes the well- 
known hoarsenes of phthisis, which is by some referred to ulceration 
near the glottis, but is by others ascribed to a reflex irritation of that 
part, arising through the medium of the pneumogastric nerve from 
the disorganisation going on in the substance of the lung. The 
characteristic symptoms of this stage are, however, the development 
of the hectic, and the puriform expectoration. 

The physical signs of softening, are flattening of the chest, increased 
dulness, and moist crepitation; the respiration being often tubular, 
but rarely bronchophonic, and the resonance of voice increased ; the 
impulse of the heart is generally feeble from incipient atrophy of 
that organ; to this, however, there are exceptions, especially in the 
more rapid cases. The characteristic sign is the moist crepitation — 
the mucous crepitation, or muco-crepitant ronchus, of some authors. 

In the fourth or last stage, that, namely, of excavation, the consti- 
tutional symptoms are still further aggravated ; the hectic fever is 
severe, the emaciation generally extreme, colliquative diarrhoea may 
be apprehended as the disease draws near to its fatal termination. 
The pulse is exceedingly small and frequent, the tongue is red and 
sometimes dry, the cheeks hollow, and the eyes sunken from the 
absorption of the fat contained in the orbits. The skin, though it 
may be at intervals hot and dry, is generally bedewed with a clammy 
perspiration. It may here again be observed that these symptoms 
are such as indicate the advanced disorganisation of the lungs, and. 
belong to extensive suppurative disease, and, therefore, that they 
generally occur when the disorganisation of the lungs is far advanced ; 
but that they are not invariably absent in the preceding stages of the 
disease of which we are treating; nor, on the other hand, does it 
necessarily follow that they will supervene as soon as excavation has 
commenced; since, in the former case, the tuberculisation and con- 



236 SIGNS OF EXCAVATION. 

sequent softening may have been so extensive and rapid as to give 
rise to the constitutional symptoms which more commonly belong to 
the stage of excavation; and, on the other hand, the disease may 
have been so limited as that a cavity may have formed before exten- 
sive softening has taken place elsewhere, and consequently without 
the hectic and other general disturbance, such as -ordinarily belong to 
that sta^e of the local disease. 

The physical signs of a cavity are increased flattening and dimin- 
ished mobility. Contrary, however, to what might have been 
expected, the resonance on percussion is almost always diminished 
over a cavity ; this is generally owing to the consolidated lung which 
surrounds the excavation as well as the dense adhesions in the cor- 
responding part of the pleura : sometimes, however, when the cavity 
is large and simple, and near the surface, a pretty sharp percussion 
elicits a ringing or almost amphoric sound, and now and then a 
sound is produced resembling that arising from a cracked iron vessel 
{bruit de pot fele)\ a multilocular cavity on the other hand always 
diminishes the resonance. The natural respiratory murmur is of 
course wanting, and in its place may be heard an omphoric sound, 
like that produced by blowing in a bottle or an empty cask; this 
sound, commonly called cavernous, has not unfrequently a metallic 
ring, and the respiration is generally attended by a gurgling sound 
like that of air passing through a considerable quantity of liquid. The 
character of this sound, even in the same cavity, will vary according 
to the quantity of the fluid which may be present, and may therefore 
change greatly from day to day, sometimes ceasing altogether, and 
then returning after a longer or shorter interval. 

Such is the general course of the constitutional and physical signs 
of this disease; but, superadded to them, there frequently arise cer- 
tain complications affecting either the lungs or other organs, and 
which may be termed the accidents of phthisis : several of these are 
of importance as they materially influence the duration of life. One 
of the first of these, connected with the lungs, is haemoptysis. This 
at the very commencement of phthisis has been already shown to be 
of importance merely as a symptom, and to retard rather than accele- 
rate its progress; but when it takes place after softening has com- 
menced, the haemorrhage proceeds in all probability from a vessel of 
some size which has been opened in the course of the ulceration, 
and becomes dangerous from its tendency to produce death from 
asthenia. The extravasation of blood may sometimes take place so 
rapidly as to obstruct the bronchi and larger tubes, and so cause 
death from apnoea or suffocation. The haemorrhage, when it occurs 
to this alarming extent, is not uncommonly produced by sloughing 
and gangrene, arising from the strangulation of the nutrient arteries 
by the pressure of the tubercles. But besides this, gangrene of the 
lung, when it supervenes in the progress of phthisis, may of itself 
cause death by asthenia. 

The first of these accidents, the haemoptysis, sometimes occurs 
without any previous symptoms ; at others, however, it is preceded 
by a fine moist crepitation and increased sharpness and frequency of 



ACCIDENTS OF PHTHISIS. 237 

tlip pulse. The symptoms of gangrene will be the same as those 
with which it is accompanied when it occurs as a primary affection, 
or as the result of pneumonia (p. 193) ; but it should be remembered 
that there may be an intolerable foetor both of the breath and of the 
expectoration towards the close of phthisis, without any gangrene 
being found after death. 

Pneumonia is of such common or rather universal occurrence in 
phthisis, that it can hardly be regarded as one of the accidents of 
the disease; unless, as it sometimes happens, it suddenly makes pro- 
gress from imprudent exposure, change of temperature, or it may be 
without any assignable cause. Under such circumstances its pre- 
sence is indicated by increased febrile excitement, pungent heat of 
skin, crepitation, and the other symptoms which ordinarily attend it : 
unless, however, it be quickly arrested by the most careful manage- 
ment, it hastens the disorganisation of the lung, and consequently 
the termination of the disease in the ordinary manner. In some 
cases it has been still more speedily fatal, where a considerable por- 
tion of the lung, having been previously blocked up by tubercles^ 
the greater portion of the remainder has been consolidated by the 
pneumonia, and death from apncea has been the consequence. 

Inflammation of the pleura is so common in the progress of phthi- 
sis that M. Louis states, he never, in a single instance, inspected 
the body of a patient who had died of phthisis, in which the lungs 
were not attached to the ribs by a greater or lesser extent of pleuri- 
tic adhesion. These inflammations of the pleura are often associated 
with tubercles on the surface of that membrane, though it may not 
be always easy to say, whether the tubercle is the cause of the inflam- 
mation, or the inflammation of the tubercle. 

These pleurisies are, for the most part, partial, and though for the 
time they may cause considerable pain to the patient, they are not 
often attended with the active febrile symptoms of simple pleurisy. 
They may be early recognised by the pleuritic friction sound, which 
however disappears when adhesion takes place. The occurrence of 
these partial pleurisies may be regarded, as a confirmatory sign of 
tuberculisation of the lungs, when, from other circumstances, we 
have reason to suspect its commencement. Another, and very com- 
mon affection of the appendages of the lungs in this disease is ulcer- 
ation of the larynx ; and this too is so frequent an accompaniment of 
phthisis, and so rarely present without it (except in syphilitic cases), 
that it may be regarded as symptomatic. These ulcers occur mostly 
in the upper part of the larynx, and often extend to the rima glotti- 
dis and the epiglottis, but affect the under surface of the latter much 
more than the upper. It is a remarkable fact, too, that they are in 
much greater numbers on that side on which the disease in the lungs 
is the most extensive ; thus it may happen, for instance, that the left 
lung being extensively disorganised by tubercular disease, and the 
right comparatively little affected, the left side of the larynx frill be 
found studded 'with ulcers, and the right almost entirely free from 
them. Another cause of sudden inflammation of the pleura, in the 
progress of phthisis, is perforation of that membrane by a vomical 



238 COMPLICATIONS. 

cavity ulcerating into it, and the consequent escape of its contents as 
well as of air into the serous lining of the chest ; the effect of this is 
generally an empyema, with pneumothorax, which is not difficult of 
detection, and of which the symptoms have been already described. 
The occurrence of this accident sometimes cuts short the life of the 
patient by death from exhaustion, owing to the depression caused by 
sudden inflammation ; but if this do not happen, the lung becoming 
collapsed, and consequently inactive, the disease is for a time arrested, 
and, if the other lung be but little implicated, life may be prolonged 
for as long a time as if the perforation had not taken place, or even 
longer ; in a case which occurred to Dr. Houghton, of Dublin, the 
patient survived thirteen months, and in one related in the Guy's 
Hospital Keports as long as three years. 

Tuberculous disease in the brain or its membranes sometimes 
manifests itself in the progress of phthisis ; the tubercles being de- 
posited in the arachnoid or on the cerebral surface of the pia mater. 
The symptoms of this complication may present themselves at any 
period of the disease, and generally commence with weight across the 
forehead, which gradually increases to most intense pain over the 
whole of the cranium, often attended with considerable stupor, but 
seldom with violent or active delirium ; the patient will sometimes 
look you most steadily in the face when speaking, and then de- 
liberately turn away his head without the slightest expression of 
displeasure. Tubercular meningitis, when it supervenes under these 
circumstances, is generally fatal in a few days. 

The serous membrane of the abdomen is often the seat of tuber- 
culous deposit in the progress of phthisis ; its symptoms are those of 
chronic peritonitis, to be more particularly noticed hereafter; to 
ulceration of the bowels allusion has been already made, and also to 
the diarrhoea which commonly attends it ; though this latter symp- 
tom may be present when there is no ulceration. Sometimes the 
ulceration gives rise to perforation, which is followed of course by 
intense peritonitis and speedy death. Sometimes the ulcers cicatrise, 
and in so doing cause contraction and consequent obstruction. 

Another very remarkable, though perhaps practically not very 
important abdominal complication is fatty degeneration of the liver : 
this morbid change does not, however, appear to be nearly so frequent 
an attendant upon phthisis in this country as the observations of M. 
Louis show it to be in France. It presents no symptoms, besides an 
enlargement of the organ and a peculiar satin-like condition of the 
skin, first noticed by Dr. Addison. Fistula in ano is a frequent oc- 
currence ; and its presence in early life should excite a suspicion of 
a liability to phthisis, if not of the existence of that disease, although 
it seems, like many other discharges, sometimes to keep the other 
symptoms in abeyance. 

Before proceeding to consider the important questions of the diag- 
nosis, the causes, and the treatment of phthisis in general, it is desira- 
ble briefly to notice its rarer form, namely acute phthisis. This 
disease has been by most authors considered under three forms : the 
first differing from the chronic merely in its greater rapidity ; the 



ACUTE PHTHISIS. 239 

second, which is perhaps the most exquisite form of acute phthisis, 
consists of a universal deposition of the grey semi-transparent tuber- 
cles throughout both lungs; and the third presenting crude and 
softening tubercles throughout both lungs, with here and there small 
vomicae. 

In the first form we have the same symptoms as in chronic phthisis ; 
but they follow each other with greater rapidity, sometimes running 
their course in two or three months, or even less. In these cases, 
however, there is often greater dyspnoea, and a greater tendency to 
venous congestion, than in the chronic ; owing to the emaciation and 
diminution of the amount of the circulating fluid not keeping pace 
with the disorganisation of the lung, and to the consequent obstruc- 
tion to the function of respiration, and the pulmonic circulation; 
there is also a greater liability to pulmonary haemorrhage from the 
more rapid ulceration of the lungs, and consequently the less time 
for the somewhat slow process of obliteration of the vessels which 
may become implicated ; the appearances presented after death are 
also the same as in chronic phthisis. 

In the second form the lungs are thickly studded throughout with 
miliary tubercles, the tissue of the organs presenting the appearance 
of pneumonic engorgement, with here and there consolidation or 
hepatisation. The disease makes its attack with well-marked febrile 
symptoms, often resembling those of acute and intense bronchitis. In 
some cases the patients may previously have been in apparently good 
health ; though we shall most commonly learn, upon closer inquiry, 
that there has been some tendency to phthisis in the family, or even 
that the patient may have had one or two slight attacks of haemop- 
tysis, or has been very susceptible to cold ; it will generally also be 
found, where any evidence upon the subject can be obtained, that 
the patient has had a quick and small pulse, with some signs of venous 
congestion. 

The final attack, however, generally commences with the ordinary 
signs of bronchitis; but the dyspnoea rapidly becomes more urgent, 
the countenance dusky or livid, the pulse very frequent and small, 
but the impulse of the heart in most cases disproportionately strong. 
The tongue is furred and much congested ; the surface is warm, and 
often moist, but the extremities are of a clammy coldness. The urine, 
too, is scanty and high coloured, and there is often a wandering, but 
sometimes active delirium. The symptoms may be summed up as 
those of extensive bronchitis of the small tubes, with a greater 
amount of obstruction to the pulmonic circulation than even this 
disease is sufficient to account for, and fever of a typhoid character. 
Upon examination of the chest, we may find diminished mobility of 
the ribs, and perhaps of the diaphragm likewise; but the former 
appear to remain somewhat elevated as if inflated, the difficulty 
seeming to be in expiration rather than inspiration. Percussion 
generally reveals but little, if any diminution of resonance. Upon 
auscultation, the sounds heard are commonly preternaturally loud 
over the whole of the chest. The inspiratory murmur is loud and 



240 FATAL TERMINATION OF PHTHISIS. 

coarse, with generally a fine mucous rattle, and the expiratory loud 
and wheezing. 

An attack of this kind may prove fatal in a few days ; in which 
case the lungs are found not to collapse, or to do so but little when 
the chest is opened, and when cut into to be in a state of excessive 
engorgement, and to be thickly studded throughout with miliary 
tubercles. The right side of the heart is gorged, and the portion of 
auricular septum occupied by the foramen ovale convex towards 
the left auricle ; the liver will also be in a state of hepatic venous 
congestion. 

If, however, the disease do not prove fatal in this stage, it passes on 
into the third form of acute phthisis, that, namely, of softening tuber- 
cles diffused through the substance of the lung. This form may, 
however, present itself without having obviously passed through the 
previous one, the attack commencing when the patient has been in 
apparent health. The general symptoms are much the same as in the 
previous form, but not so rapid in their progress, and the dyspnoea 
and lividity, though considerable, are less urgent, and the commence- 
ment of the febrile symptoms not so strongly marked. The rigors 
are often repeated for several days, and are generally followed by heat 
and perspiration ; but there will commonly, as in the former case, be 
a coldness and clamminess of the extremities, with a feeble pulse at 
the wrist, but considerable impulse of the heart.. The cough will 
generally be attended with expectoration of mucus, which soon be- 
comes opalescent and puriform. Pain will not unfrequently be felt 
across the epigastrium and along the margin of the ribs, especially on 
the right side, the effects of engorgement of the liver and spleen from 
obstructed pulmonic circulation; and the urine will be scanty and 
loaded, and not unfrequently there will be diarrhoea, with tenesmus. 
Hectic and emaciation now rapidly come on, the expectoration 
becomes more and more puriform, and the patient dies mainly of 
exhaustion, but still with a considerable tendency to apncea, gene- 
rally within ten or twelve weeks of the commencement of the illness. 

Upon exploration of the chest we find that there is slightly -dimin- 
ished mobility, and the general resonance of the chest is impaired. 
At the commencement there is dry ronchus, but soon there is fine 
mucous rattle, which gradually becomes larger, or assumes the charac- 
ter of mucous crepitation, which passes on to gurgling. 

Phthisis, it is well known, is a most frequent disease in all climates ; 
but in this more especially: it is also a most fatal one, though not, 
perhaps, so certainly or necessarily as is generally believed: the 
modes in which it proves fatal are various. In the chronic form, and 
when the fatal termination is not hurried on by any of what have 
been spoken of as the accidents of phthisis, the patient dies from 
asthenia or protracted syncope ; owing to the great extent of suppura- 
tion in the lungs, aided in most cases by the diarrhoea; just as would 
be the case from similar disorganisation in any other part. Death in 
this form of the disease rarely, if ever, is the direct result of apnoea, 
neither do we find in the heart or liver the ordinary results of obstruc- 
tion to the pulmonic circulation, owing to the volume of blood being 



DIAGNOSIS. 241 

greatly diminished by the protracted suppuration; and accordingly 
the heart is generally found to be small, and neither ventricle immo- 
derately distended; the liver also is not usually congested. The 
modes of death from the various accidents of phthisis have been 
already described. In the acute forms they are altogether different, 
being more or less owing to the obstruction, of the function of the 
lungs. In the case of rapid excavation the mode of death is less 
widely different from that in chronic phthisis ; there being consider- 
able emaciation and exhaustion ; but nevertheless, urgent dyspnoea, 
and after death the right side of the heart is distended, and the liver 
congested. In the case of miliary tubercles, on the other hand, the 
mode of death is purely apnoea, the patient being often perfectly 
livid, and there then being every sign after death of the greatest 
obstruction to the pulmonic circulation, the subject being but little 
emaciated, or even in full flesh. 

The diagnosis of phthisis is, as must be obvious, a matter of the 
greatest importance, not only as regards treatment, but, which is of 
hardly less moment where so fatal a malady is in question, as regards 
prognosis. It must also be apparent that it is of no less importance 
to detect the disease at its commencement ; and it is at this time that 
it is also the most difficult. It may be that even before its com- 
mencement, or at all events before* there have been any cough or 
expectoration, or any of those symptoms which peculiarly belong to 
it, the question of the danger impending phthisis is submitted to us. 

The premonitory symptoms having been already described, it re- 
mains to notice a few of the disorders which may be mistaken for early 
phthisis. The first of these in point of order, is, perhaps, dyspepsia, 
the diagnosis between which and early phthisis, will generally arise 
only in persons in whom there is supposed to exist some previous 
tendency to the latter; and in such subjects, or, in other words, in 
young adults of phthisical families, or in whom the general symp- 
toms of tuberculous diathesis are present, obstinate dyspepsia is to 
be watched with anxiety ; and if to this there be added a furred and 
red tongue, not to be accounted for by any transitory febrile disturb- 
ance, the danger is greater ; or if such a subject, not being a dissi- 
pated person, steadily lose flesh without any assignable cause, there 
is a strong probability of his becoming phthisical. 

A most important question arises in young females, from amenor- 
rhoea. In ordinary amenorrhoea, or in chlorosis, there is generally a 
gradual diminution in the menstrual discharge before its entire sup- 
pression; in phthisis, on the other hand, the cessation is almost 
sudden. Still, amenorrhoea has been mistaken for phthisis, and, 
what is of more serious consequence, the latter for the former ; there 
may be amenorrhoea, with haemoptysis, without phthisis ; but sudden 
amenorrhoea, with cough, and expectoration streaked with blood, is 
probably the beginning of phthisis, and if with this there is obstinate 
bronchitis of one or both apices, the symptoms are still more unfa- 
vourable. Closely connected with the above is the diagnosis from 
haemoptysis without tubercle ; in the female, haemoptysis with amen- 
orrhoea is more alarming when occurring in small quantities, and 

16 



242 PHTHISIS. 

mixed with mucus, than when the blood is pure and in larger quan- 
tities. In the young adult male, where there is no disease of the 
heart, or aneurism, if there be haemoptysis, there is probably phthi- 
sis, and the diagnosis becomes almost positive if there be obstinate 
bronchitis of the upper lobe. Malignant disease of the lung may 
form an exception, but this is rare in such subjects ; and when it is 
present, the character of the expectoration resembling red-currant 
jelly, as well as the general and local symptoms, will enable us to 
recognize it. 

The discrimination of simple bronchitis from early phthisis is the 
question that we are perhaps most frequently called upon to decide 
in regard to the diagnosis of the latter. If to bronchitis of the small 
tubes there be added diminished mobility of the upper ribs — im- 
paired resonance over the apices- — increased loudness of the sounds 
of the heart in the same situation — irregular or jerking respiration 
— haemoptysis or raucedo — there is probably phthisis, and this pro- 
bability is still greater if the pulse be persistently more than 100. 
Emaciation is also an important symptom under these circumstances ; 
but it must be remembered that tubercles and even cavities may be 
present in the lungs, and the patient recover flesh, when the progress 
of the disease is merely checked for a time. 

Pleurisy has an important bearing upon the diagnosis of phthisis. 
Frequent attacks of limited and apparently erratic pleurisy are 
alwa}^s unfavourable, and still more if subacute or chronic peritonitis 
be also present. It is stated by Louis, that when the latter disease 
exists in a person of more than fifteen years of age, provided cancer 
be not present, there is also phthisis ; to this exception there has 
been added that of Bright's disease ; but even thus qualified, the law, 
though generally, is not universally true. Double pleurisy, with 
effusion, has been stated to be almost certainly indicative of phthisis ; 
but besides the common exception of Bright's disease, and the rarer 
ones of malignant disease, and puriform infection, there may be (pos- 
sibly from rheumatism) double pleurisy with effusion, without phthi- 
sis, though almost always in an acute form. Sometimes there is a 
great depth of solid matter effused on the surface of the pleura ; this, 
when it occurs near the apex, will produce diminished resonance, 
tubular breathing, and flattening, which may be supposed to arise 
from phthisis. This state of things is, however, much more common 
with the latter affection than without it, and if there be signs of dis- 
ease in the corresponding part on the other side, though these signs 
be almost entirely referable to the pleura, the diagnosis of phthisis 
becomes almost positive. 

The diagnosis between phthisis and pneumonia is often difficult, 
and in many cases we must be satisfied with a merely conjectural 
one, since pneumonia supervenes upon tubercular disease ; and may 
be followed by it, if it be not its cause. It is impossible, therefore, 
as long as pneumonia exists in either apex, to say, that there may 
not be phthisis ; and so much more common is this disease than 
simple pneumonia in that part of the lung, that the probability is 
always in favour of phthisis ; though the diagnosis must be consid- 






DIAGNOSIS. 243 

ered doubtful, until mucous crepitation or some unequivocal symp- 
tom is detected, either in the other apex, or in the neighbouring 
portion of the same lung ; or some of the more characteristic consti- 
tutional symptoms make their appearance ; or, on the other hand, 
until the subsidence of the former, and the continued absence of the 
latter, lead to the belief that the consolidation is dependent upon a 
disease confined to that part, a conclusion strongly at variance with 
the apprehension of phthisis. 

There may also be a difficulty in the diagnosis between the more 
advanced stages of phthisis and pneumonia. "If," observes Dr. 
Addison, '"acute pneumonia have already proceeded to complete 
hepatization, when we first examine the patient, the physical signs 
are not unfrequently insufficient to distinguish the morbid change 
from phthisical disease, or from ancient pneumonic induration, with 
or without dilated bronchial tubes. This is more especially the case 
when acute pneumonia assails the apex of a lung, which is by no 
means very uncommon." 

It will generally be — by the previous history of the case, — by the 
disease having come on more slowly and insidiously, — by the greater 
amount of emaciation, — the greater tendency to hectic, — the less 
pungent heat of the skin, that we may often be able to distinguish 
the chronic tuberculous phthisis. The acute phthisis is not so likely 
to be mistaken for pneumonia of the apex, owing to its more diffused 
character, except in the case of the first form, in which, no doubt, 
the difficulty is the greatest ; but even here the state of the opposite 
lung — the character of the fever — the previous history of the case, 
will generally enable us to solve the difficulty ; still the diagnosis is 
a difficult one, and the difficulty must be borne in mind in the treat- 
ment of the case, by carefully watching it's progress and the effects 
of remedies. It is not very often that a question arises between 
fever and phthisis, still, as was first pointed out by M. Louis, the 
acute miliary phthisis (form 3) often closely simulates typhus fever 
of the congestive character ; the eruption of fever when it occurs, and 
is observed, of course decides the question. 

When there is chronic peritonitis, if bronchitis, or diminished 
resonance of the apices arise, or even if there be increased resonance 
of the voice, or loudness of the sound of the heart in that situation, 
there is probably phthisis. 

Persistent, or frequently-recurrent diarrhoea is always a premoni- 
tory sign, in a young adult of tuberculous diathesis, and if to this 
there be added any of the topical signs, the case is almost certainly 
one of phthisis.* 

The treatment of phthisis has generally been considered either as 
prophylactive or palliative ; the former applying chiefly to those 
cases in which, from family predisposition, or other causes, the dis- 
ease may be apprehended ; the latter to those in which there is satis- 
factory evidence of its existence ; this distinction being based upon 
the assumption that when the disease is once established, its removal 
is a thing quite beyond the reach of art. 

* Dr. Walshe's "Diseases of Lungs and Heart." 



244 PHTHISIS. 

The question as to whether we are to regard the treatment of inci- 
pient phthisis as curative or prophylactic, is not of very great prac- 
tical value, though it is not entirely without its influence upon our 
views of the principles according to which the management of the 
disease is to be conducted. Since, if according to the opinions 
already expressed (p. 230) there must be a lesion antecedent to the 
deposition of tubercles, we have, at this period, a disease to treat, — 
and one from which there are good grounds for believing that many 
have recovered, — and, whether that recovery be regarded as sponta- 
neous, or as the effect of art, it cannot be supposed that it would 
have taken place under other than favourable circumstances, both 
external and internal ; and, therefore, the rational mode of proceed- 
ing must be to endeavour to ascertain those circumstances, and as 
far as possible to imitate them ; and the same reasoning holds good 
of the far less frequent instances of recovery in more advanced 
stages, the cessation of the disease in the manner described (p. 228) 
being a result more opposed to experience than to any known laws 
of pathology. 

As regards the strictly preventive or prophylactic treatment of 
phthisis, it consists in measures calculated to prevent the develop- 
ment of the tuberculous diathesis, where it is to be apprehended ; 
and where it exists, to obviate all circumstances tending to promote 
irritation, excitement, or even undue activity of the respiratory 
organs ; and where such irritation has arisen, to endeavour to subdue 
it as speedily as possible, without having resource to such measures, 
as, by lowering the reparative poAvers, would favour the general 
tendency to tuberculous disease. 

As to the first of these indications, namely, the preventing the 
development of the tuberculous diathesis, precautions should be 
most strictly enjoined for the avoidance of all those circumstances 
(under our control) which have been already pointed out (pp. 110 et 
seq.) as favouring it, and the cautious use of such means as may be 
expected to have a contrary tendency. 

As to the prevention of the determination of the tuberculous 
diathesis to the lungs, we must again recur to what has been stated, 
when treating of the circumstances influencing the location of tubercle 
(pp. 112 et seq.). It is about the age of puberty that the greater 
expansion of the respiratory organs, arising from a greater need for 
the activity of their functions, suggests the necessity for increased 
precaution against their becoming the seat of tubercle ; for, although 
the deaths from phthisis between the ages of fifteen and twenty are 
many less than those between twenty and twenty-five ; there can be 
little doubt that, in by far the greater number of instances, the disease 
has its origin during the former period. 

It becomes then a matter of great importance, in the management 
of young persons in whom a tendency to phthisis may be apprehended, 
to use every possible precaution to obviate determination of blood to 
the lungs, as well as undue excitement of those organs. 

In the first place, the obvious and ordinary rules of diet, clothing, 
air, and exercise, which are, however, but too commonly neglected. 



PROPHYLACTIC TREATMENT. 245 

cannot be too carefully followed; though, as regards diet, it must of 
course be nutritious, but not stimulating ; in moderate quantities, 
and at reasonable intervals, so as to avoid the extremes of exhaustion 
and repletion, and prevent the undue afflux to the digestive organs, - 
and consequent languid circulation of the extremities. 

Determination to internal organs, and especially to the lungs, must 
also be guarded against by a careful attention to the temperature and 
circulation of the surface. Uniform, but not very warm clothing, is 
an important means to this end ; and it must be used in subservience 
to the principle of preventing the sudden or too rapid abstraction of 
the animal heat, but not employed to such an extent as to diminish 
the activity of those functions upon which the evolution of this heat 
depends. Light woollen clothing should be employed in some form, 
for the whole of the body below the clavicles, and where there is a 
tendency to irritation about the larynx, a thin layer of flannel or 
woollen gauze may be worn round the throat: where a uniform 
system of under-clothing of this kind is adhered to, there will be 
no occasion for oppressing the body with a load of outer-garments. 
The same remarks apply to night-covering, though it will not generally 
be desirable that the patient should sleep in flannel. The night-dress 
should be calico, and if there is much coldness of the feet, woollen 
socks may be worn. Before quitting the subject of clothing, we 
must not omit to notice the mischiefs which may arise from undue 
pressure or constraint. The apices are the parts first attacked, and, 
therefore, whatever causes increased activity of that part of the luog, 
promotes the disease, and this cannot be done more effectually than 
by compressing the lower lobes by tight stays or waistbands. 

The questions of air and exercise — in the former of which we may, 
for the sake of brevity, include climate — are at this period particularly 
important. In the case of a young person in danger of phthisis, whose 
growth is not completed, we must not only avoid circumstances likely 
to cause too great determination to the chest, but, as far as we can, 
prevent such a development of the system as would call for more 
than an average amount of respiratory function. It is a common 
observation, that young persons of a phthisical tendency have narrow 
chests, their lungs not being sufficiently developed ; and, therefore, it 
is inferred, somewhat hastily, that the narrowness of the chest is the 
cause, or rather the essence of the phthisical tendency ; the converse, 
however, is more nearly the truth, namely, — that, when the tendenc} 7- 
to tuberculous deposit in the lungs is present, there is an instinctive 
avoidance of that exercise which would promote the morbid change ; 
and, therefore, the lungs being less active are less developed. It must 
be borne in mind, then, that whilst a defective expansion of the lungs 
is of itself a source of most serious and even fatal lesion, though not 
of tubercle, their full or even moderate development, may call the 
tuberculous diathesis into activity ; and, in the management of the 
class of patients we are now considering, the regulation of air and 
exercise must be conducted with a view to favouring the gradual 
expansion of the lungs, without inducing that amount of respiratory 
function which is excited by a cold atmosphere, and without such 



246 PHTHISIS. 

vigorous exercise as stimulates the rapid development of the muscular 
system. With this view, a mild and uniform climate, but, as a general 
rule, one free from humidity, should be selected ; and for this purpose 
many parts of the southern shores of this island are well adapted, as 
Hastings, the West Cliff of Brighton (during the autumnal and winter 
months), Bournemouth or Clifton. Though for those in whom, to 
use the words of Dr. Walshe, there is a greater tendency to the 
striatum in the constitution, Yentnor, Torquay, Budleigh, Salterton, 
Sidmouth, or the coast of Cornwall, as Penzance or Flushing near 
Falmouth, and the Cove of Cork, will be better adapted as winter 
residences. One great advantage of a mild climate is, that there need 
be less difference in temperature between the external and internal 
air, and that, consequently, exercise may be taken out of doors 
without the risk arising from changes of temperature ; and that such 
exercise may be sufficient to keep up the warmth of the surface, and 
excite a moderate action of the lungs, without so far exciting them 
as to promote the determination of the disease to them. Walking, 
when it does not embarrass the respiration, is upon the whole the 
best exercise; but where the patient's strength is soon exhausted, or 
where the breathing is easily hurried, riding [on horseback] is to be 
preferred, provided that it does not cause coldness of the extremities. 
In warm weather carriage exercise is beneficial, as is also sailing, or 
being rowed in a boat, where it does not induce sickness. 

It is at this period that irreparable injury has often been inflicted 
by the use, or rather abuse, of athletic games or exercise, pursued 
sometimes even under medical sanction, from the mistaken notion of 
obviating the tendency to contraction of the chest so common in 
subjects of this class ; whereas, from what has been already stated, 
the expansion of the lungs, and the development of the muscular 
system, must be most undesirable ; and for the same reason the 
greatest caution is necessary, in allowing the use of such exercises as 
rowing, cricket, &c, in youths in whom there is a narrow chest and 
suspected tendency to phthisis ; though where this contraction arises 
from causes to be hereafter noticed their moderate use is admissible. 

Another important question often asked in such cases is, the 
expediency of bathing; now where, as it often does, the arterial 
system seems disproportionately defective as compared with the 
venous, the pulse being in such cases small and feeble, sea-bathing 
is seldom safe ; as, under such circumstances, there would probably 
not be sufficient power in the left ventricle to drive the blood again 
to the surface, and internal congestion, probably of the lungs, would 
ensue. When, however, as we now assume to be the case, there is 
no evidence of present lesion of the lungs, and the pulse is moderately 
full, and there are no signs of venous congestion, or of engorgement 
of the right heart, or other circumstances contra-indicating its use, 
careful bathing in the sea may be allowed. Such bathing should 
generally be about an hour and a half after breakfast, and the patient 
should not remain long in the sea, neither will it be generally desirable 
that he should plunge suddenly in, but he should step from a machine 
feet foremost, immerse the whole body and head, and return. He 



TREATMENT OF IMPENDING PHTHISIS. 247 

should on no account go cold into the water ; but, on the contrary, a 
slight increase of temperature induced by exercise is rather desirable. 
Where bathing is not admissible, sponging the chest both in front 
and behind with cold water can generally be borne, and where it is 
followed by a moderate glow it is a most valuable aid in promoting 
the activity of the circulation in the superficial capillaries. 

The period of impending phthisis is of course not a time for active 
medical treatment, though it is one for very careful medical superin- 
tendence. In regard to medicine the same principle must be carried 
out as in the hygienic management ; the general strength and nutri- 
tion must be cared for, and undue excitement of the respiratory 
function guarded against : as a means to these ends attention to the 
digestive organs is indispensable. With this object in view, it will 
be necessary, in addition to the careful attention to diet enjoined 
above, to insure a regular action of the bowels ; the irritating purga- 
tives must be avoided ; as, besides their other ill effects, they depress 
and derange the circulation ; but an occasional dose of rhubarb and 
sulphate of potass will be of service: or, if the bowels be habitually 
costive, a dessert spoonful of olive oil, taken early in the morning, 
will have the effect of relieving them without risk of irritation, or 
sometimes about half a drachm of the extract of taraxacum taken 
early will have the same affect. This last has also another advantage, 
if, as Dr. Baillie used to assert (and as there is reason to believe to 
be the case), it may be regarded as a vegetable mercury, exciting the 
action of the liver ; for that organ being, in regard both to circulation 
and function, closely connected with the lungs, affords a ready channel 
through which to relieve them. The maintaining the action of those 
organs which may be regarded as in any way supplementary to the 
lungs, should never be lost sight of; and as this applies especially to 
the liver, the state of the stools and urine should be watched ; and 
when the secretion of bile appears defective, it should be promoted, 
not by mercurials (except sometimes a moderate dose of hydrarg. 
cum. cret. with rhubarb) but by taraxacum or the laxative just 
recommended. 

Besides the liver and bowels, the kidneys afford a means by which 
to relieve the circulation of the system generally, and consequently 
in the chest, and therefore the state of the urine should be regularly 
observed, and as its becoming turbid will generally depend upon 
partial obstruction, arising probably from incipient pulmonic conges- 
tion, the aperient should be given, and for a time moderate diuretics. 
The extract of taraxacum with about ten grains of bicarbonate of 
potass and twenty minims of sp. seth. nit. in bitter infusion, will often 
have a good effect in this way. 

The earliest symptoms of bronchitis, or any other thoracic inflam- 
mation, should of course be promptly met by decided but not over- 
active treatment ; all needless depression of the powers of the system 
only aggravating the tuberculous tendenc}^. In case of bronchitis, 
which is the more ordinary form of disease, salines, with small 
doses of antimonial or ipecacuanha wine, about five grains of extract 
of conium every night, or night and morning; and, after a few days. 



24:8 PHTHISIS. 

the application of a blister, if the irritation continue after the febrile 
symptoms have subsided, will generally be sufficient. The conium 
mixture will also be found a most useful medicine under such circum- 
stances. Where pneumonia or pleurisy occur, they must be treated 
iipon the principles already laid down, but with a more cautious use 
of depletion, and a no less scrupulous one of mercurials. The local 
abstraction of a small quantity of blood by cupping or leeches, over 
the inflamed part, will in either case be generally well borne, and 
expedite the resolution of the inflammation with the least loss of 
strength to the patient. 

Dr. Graves, indeed, as well as several other Irish pathologists, and 
Dr. Munk in this country, have strongly recommended rapid mercu- 
rialisation in such cases; but it is not a practice which has extensively 
obtained the confidence of British physicians. [In all cases such a 
practice, we are persuaded, would be rather calculated to accelerate 
than retard tuberculous disease of the lungs.] 

It is not generally desirable, in the absence of any decided symp- 
toms of disease, to put such patients under a course of medicine. 
Where, however, there is emaciation, a course of the cod-liver oil, 
continued for three or four weeks, and resumed, if necessary, about the 
same time after its discontinuance may be of service ; and where there 
is an exsanguine appearance, iron, in the form of small doses of the 
citrate, or of the syrup of. the iodide, should be employed. The use 
of iron is often specially applicable to females (it being observed that 
we are now speaking of young persons just about, or past the age of 
puberty, in whom there is a tuberculous diathesis but no apparent 
pulmonary affection), as the delay or arrest of menstruation is, in 
young females prone to phthisis, not only an unfavourable symptom, 
but may be in itself a cause of pulmonic irritation ; for the connection, 
elsewhere pointed out, between the uterine functions and the evolu- 
tion of carbonic acid, renders it highly probable that the suppression 
of the catamenia must promote the development of tubercle in the 
lungs. 

When a young subject of this class is affected with any strumous 
ulcer, diseased bone, or fistula in ano, it is doubtful whether the 
healing of these is desirable. It is certain that, in some cases, the 
more active symptoms of phthisis have supervened upon the healing 
of such ulcers, and have subsided upon their reappearance in the same 
or some other part. It appears, then, most expedient to use no active 
measures to heal them, except in so far as that result can be brought 
about by improving the general health. When, as in case of very 
unsightly strumous ulceration of the skin, any application is used for 
that purpose, it would be well to establish some compensating dis- 
charge, as an issue or seton on the surface of the chest. The best 
internal remedy under such circumstances is the iodide of iron. 
With regard to fistula in ano, experience is strongly opposed to the 
expediency of the operation for its cure; unless the amount of dis- 
charge, and the consequent drain upon the system, be so great as to 
become almost a greater evil than phthisis. 

In speaking of the prophylactic management of young persons in 



TREATMENT OF FIRST STAGE. 249 

whoni phthisis may be apprehended, we have said nothing of removal 
to a distant climate, as it is a question which belongs more to the 
treatment of the first stage, in which the premonitory symptoms of 
phthisis begin to show themselves locally; indeed it may well be 
doubted whether it is expedient to send young persons in whom the 
development of the system is complete, to an intertropical climate, or 
even to a low latitude, since it is highly probable that the return to 
this country would be attended with a double danger. 

In the treatment of what we have styled the first stage of phthisis, 
that, namely, which immediately precedes tuberculisation, the prin- 
ciples above laid down must still be acted upon, namely, to avert 
irritation or inflammation in the lungs, and to maintain the nutritive 
powers of the system. But at this period, when the disease may be 
said to be impending, if not already existing in the lungs, we may lay 
greater stress upon the former clause, and direct our remedies more 
particularly to the lungs. 

It is now that the greatest benefit may be hoped for from change 
of climate ; but this change must be made for a sufficient time ; and, if 
a removal from this to another country be decided upon, it should be 
to one climate decidedly different from that in which the patient has 
been hitherto residing. Dr. Graves observes, and with reason, that 
it is needless to send a patient from these islands to the south of 
France, or to the Mediterranean;* and that a change beyond the 
limits of Europe should be made. Madeira is, perhaps, the nearest 
place, and the convenience of access to that island is certainly a 
recommendation ; but the greatest benefit, probably, is to be obtained 
by a residence at the Cape, or in the West Indies, or a voyage to the 
East Indies. 

Of course it is of the first importance to prevent any inflammation 
of the lungs or their appendages, but where such does occur, it must 
be treated upon the principles already laid down (p. 248), and any 
more trifling irritation, as catarrh or slight bronchitis, by light diet, 
and the conium mixture with a little ipecacuanha wine. When the 
symptoms, general or local, indicate an increased determination to 
the lungs, a very small amount of blood may be taken, by leeches or 
cupping, from under the clavicles; or dry cupping may be used. 
Occasional blisters may also be applied, when there is not too much 
heat of skin ; or the tartar-emetic ointment employed. A valuable 
method of counter-irritation is the application to the chest of the 
plaster recommended by Dr. Hughes (F. 31).f The pulse in this 
stage of the disease is generally rapid, and it is important, in some 
measure, to control the heart's action; for this purpose digitalis will 
sometimes be useful, and the infusion will be the best form for its 
exhibition, as, although it does not so directly depress the heart's 

* Malaga, however, presents many of the advantages of a more southern climate- 
See Dr. Francis on Change of Climate. 



•j- (31) R. Emplast. Picis co. giss. 
Anti. Pot. Tart. gr. x. 
Dissolve and mis. 



250 PHTHISIS — HEMOPTYSIS. 

action as the tincture its more diuretic properties are serviceable 
(F. 32) * 

Where there is no active irritation of the lungs or bronchi, the 
digitalis may be advantageously combined with iron or quinia, or 
both, as in the pills (F. 33) :f where the quinia or steel may be too 
stimulating, the sulphate of zinc will be found a most useful tonic 
(F. 34)4 and this more especially in those cases where the skin is 
generally moist. Another useful medicine will be the conium in 
combination with sarsaparilla, in the form of the conium mixture, 
with about fifteen grains of the solid extract, or 3i. to 3ij. of the 
liquid. 

If there be emaciation, the cod-liver oil will be of service, but 
otherwise it is rarely so in this stage of the disease. 

It is not unfrequently at this period that haemoptysis occurs, and 
when it does so, it must be treated accordingly ; but it must be borne 
in mind that when not very great, it is to be regarded rather as a bad 
symptom than as in itself a cause of mischief, since it is by no means 
impossible that it may give relief, by diminishing the hyperaemia, 
which is its cause. 

It is rarely, if ever, expedient, under these circumstances, to take 
blood from the arm, but cupping under the clavicles to two or three 
ounces is generally admissible. Where it is obvious that one lung is 
much more affected than the other, that side may be selected ; if the 
pulse be quick, digitalis with acid may be employed, as in (F. 32); 
and should the haemorrhage be of such an amount as to become of 
itself a source of weakness, about ten grains of alum, or five of gallic 
acid may be added. Lead has certainly considerable power over 
haemorrhage from the lungs, but the other astringents are to be pre- 
ferred to it when there is much tendency to anaemia. When, however, 
the haemorrhage is very great, threatening death from exhaustion, the 
stronger styptics, as turpentine, may be employed, and cold applied 
to the surface of the chest. The latter, however, is a remedy to be 
used with the utmost care, as we have seen more than one instance 
in which there was too much reason to believe that, by the applica- 
tion of ice to the chest, and the neglect of cautions to prevent the 

* (32) R. Infus. Digitalis, giij. 
Tinct Hyoscyam. t ^ij. 
Sp. JEth. Nit. 5 iij. 
Syrnpi Rhasad, 3 iiiss. 
Acid Sulph. dil. gss. 
Infus. Rosas co. ^ iij. M. 
A third part to be taken three times a day; add, if indicated, Quiniae Disulph. gr. j., to 
each dose. 

f (83) R. Pulv. Digitalis, 

Quiniae Disulph. aa gr. j, 
Ferri Sulphat. gr. ss. 
Ext. Conii. gr. iiss. M. 
Ft. Pil ; to be taken three times a-day. 

% (34) H Zinci Sulphatis, gr. i. 
Ext Conii, gr. iv. M. 
Ft. Pil. ; to be taken three time a-day. 



TREATMENT OF LATER STAGES. 251 

patient being wet with, ice-cold water, congestion, pneumonia, and 
speedy death, were the consequences of over-nmch zeal in checking 
haemoptysis in this manner. When ice is applied, it should be care- 
fully tied up in a bladder, and the effects upon the general tempera- 
ture of the surface carefully watched. 

There is good reason for believing that, in many cases of this 
description tending, under unfavourable circumstances, to tuberculi- 
sation and softening of the lung, the disease has been arrested by 
measures such as we have been recommending, and that, too, in cases 
where a removal from this country has not been practicable. 

The treatment of the next two stages, those, namely, of tuberculi- 
sation and softening, must be nearly the same, if, indeed, these 
stages can often be separated: but the object in either case is to 
allay irritation, and at the same time maintain the powers of the 
system, and to treat any of the accidents or complications of the dis- 
ease, which may now be expected to present themselves, as they 
arise. It will be of great importance to allow the lungs as great a 
degree of repose as is consistent with the general health, and particu- 
larly to preclude all those circumstances which might be expected to 
call upon them for any sudden or hurried increase of action. This 
is mainly to be effected by a uniformly- warm temperature. At the 
same time, however, in the absence of all the accidents above alluded 
to, we must not lose sight of the principle of maintaining to the 
utmost the healthy nutrition of the system. The selection, where it 
is possible, of such a climate as will allow of the patient passing some 
time in the open air, or even taking moderate out-door exercise 
without incurring any considerable change of temperature, or indeed 
of at any time breathing an atmosphere below 60° F., is a most 
important means to this end; and therefore, where the disease is not 
far advanced, or likely to be very rapid in its progress, a removal to 
a warmer climate, as the Cape, or to Madeira, may yet be attempted; 
but it should not be encouraged by the medical attendant without an 
express intimation to the friends of the patient of the doubtfulness of 
his living to return ; and, therefore, one of the places in this country 
already alluded to will often be preferred. Even in these, for many 
months in the year, it will be possible to obtain fresh air without 
violating the above conditions; and when the external temperature 
is not below 60°, artificial warming of rooms should be dispensed 
with, and the windows freely opened. The diet should be nutritious, 
but unstimulating : mutton, or white fish, or game, being allowed 
once, and when there is much debility, twice in the day. The 
clothing should still be uniform, but not oppressive, and composed of 
materials that are the worst conductors of heat. As regards medi- 
cine, the conium mixture, with the sarsaparilla, or two or three 
minims of the dilute hydrocyanic acid, will still be found useful, 
especially if the cough be troublesome, and even at the same time the 
cod-liver oil may be used, adding to it, as Dr. Walshe recommends, 
a little mineral acid if it offend the stomach, and, when the bowels 
are irritable, a few drops of laudanum. It may sometimes be con- 



252 PHTHISIS. 

veniently given, in such cases, floating on the draught (F. 35).* The 
conium mixture may be given night and morning, and the oil about 
an hour after each meal. Where the cough is not a troublesome 
symptom, it will be best to discontinue all medicines except the oil, 
though it will often be found, after a time, that patients who have 
been taking it without repugnance, suddenly conceive an unsur- 
mountable antipathy to it; in which case it must of course be with- 
held ; after some time, however, the patient will express a willingness 
to resume its use, and it will then be found to be as serviceable as 
before; indeed, the alternation of the conium and sarsaparilla with 
the cod-liver oil, appears to be a very beneficial course of medicine. 

Another important consideration at this period of the disease is the 
obtaining sleep; indeed, sleep is one of the best remedies in con- 
sumption, as it is the most effective and most natural means of giving 
rest to the respiratory organs. 

The extract of hyoscyamus, in combination with that of lettuce, 
will often be a useful anodyne, but when this fails, opium or morphia 
may be employed (F. 36).f Morphia with henbane is a very useful 
combination. It ought perhaps to have been first stated, that the 
best of soporifics is fresh air, and that, when the patient can be much 
out of doors, there will not often be occasion for any other. 

The treatment of the last stage, or that of excavation, can of course 
be but palliative; but even here it must be remembered that cases 
do occur in which there has been a cavity, and that too of conside- 
rable size, but where the rest of the lung having been free from dis- 
ease, the cavity has emptied itself, and ultimately, by the contraction 
of the lining membrane, been nearly obliterated; or in which the 
symptoms, both topical and general, have so closely resembled this 
state of things, that it has been next to impossible to distinguish 
them: so that we are still called upon to omit no precaution to avoid 
irritation of the lungs, or any means to maintain the nutrition of the 
system; for which purpose the same measures must be pursued as 
heretofore, and to this end the cod-liver oil will still be found most 
serviceable. A nutritious, but unstimulating system of diet must 
still be pursued, though, where there is much exhaustion, the mode- 
rate use of wine or malt liquor may be allowed ; of the latter the 
best is, perhaps, pure single stout of the London brewers. 

When there is any increase of cough or expectoration, the conium, 
with a little ipecacuanha, may be again employed, and counter-irrita- 
tion may be established over the cavity by a small blister, or the 
tartar- emetic ointment. It is in this stage that the night-sweats are 

* (35) R. Acid Nit. dil. ^ x. 
Tinct. Opii, tt^ ij. 
Syrupi Aurant. ^ i. 
Infus. Aurant. co. 3 vj. Misce. 
Ft. haust. 

f (36) R. Morphise Hydrochlor. gr. i. 

Ext. Hyoscami, gr. xvi. Misce. 
Ft. Pil. iv. of which one is to be taken at bed- time. 



TREATMENT OF LATTER STAGES. 253 

most troublesome, and against them there is no remedy equal to the 
combination of zinc and hyoscyamus (F. 37).* 

It is often in the latter stages of phthisis that the irritation from 
the laryngeal ulceration is the most troublesome. Where this is the 
case, the solution of nitrate of silver should be applied in the manner 
recommended for chronic laryngitis. Where, however, there is any 
irritation from this cause in the commencement of the disease, the 
strong solution may be employed, not only with advantage to the 
affection of the throat, but apparently with benefit to that of the 
lungs as well. 

The complications or accidents of phthisis may be treated upon 
ordinary principles. The partial and erratic pleurisies which so fre- 
quently occur may be combated by the application of small blisters, 
occasionally mustard poultices ; the intercurrent pneumonias in this 
disease may be treated upon the principles already laid down, 
although the details given for the management of active pneumonia 
would of course be inapplicable here ; for we must remember that 
the pneumonia which we have now to do with is of a disorganising 
character, and, therefore, that mercury in considerable quantities, 
and other lowering measures, should be abstained from. Antimony, 
where there is much heat of skin, and the bowels are not irritable, 
may be administered in small doses, and a little Dover's powder and 
hydrarg. cum cret. given at night, or night and morning. When the 
inflammation is of a decidedly active character, a few leeches may be 
applied over the inflamed portion of lung, or two or three ounces of 
blood removed by cupping. Haemoptysis, when it occurs, as also 
pneumothorax, must be treated in the manner already recommended. 

Sickness is often, though not very often, a distressing incident in 
phthisis; it generally, however, is the effect of some abdominal com- 
plication, as strumous disease of the glands about Glisson's capsule; 
it may frequently be combated by effervescing draughts, to which 
may be added small doses of prussic acid; or by soda or Seltzer 
water, given in small quantities at a time ; or, where there is much 
irritability of the mucous membrane, as shown by redness of the 
tongue, by restricting the patient, for a time at least, to the use of 
milk and lime-water in about equal proportions, applying at the same 
time blisters or sinapism. 

Diarrhoea is anmher very troublesome symptom, and particularly 
towards the termination of phthisis ; it occurs, however, not uncom- 
monly (as we have seen) in the earlier stages, when it is probably 
excited by irritating matters in the alimentary canal, under which 
circumstances gentle laxatives may be employed, as castor oil and 
laudanum, castor oil and tincture of rhubarb (F. 38), f or the combi- 

* (37) R. Zinci Sulphat. gr. i. 

Ext. Hyoscyam. gr. iv. Misce. 
Ft. Pil. ; to be taken each night, at bed- time. 

f (38) R. Olei Ricini 

Tinct. Rhei, a a 3 ij. 

Tinct. Opii, irL iv. 

Aq. Ciunam. 5 ss. Mix, and intimately diffuse the ingredients. 



254 PHTHISIS. 

nation of rhubarb and chalk and opium (F. 39).* In the latter 
stages of phthisis, when there is probably ulceration of the bowels, 
the diarrhoea is best combated by astringents, as copper and opium, 
compound kino powder, nitrate of silver, logwood, &c. A very use- 
ful astringent or tonic is the combination of nitric acid and tincture 
of opium (F. 40).f Enemata of starch and laudanum are also appli- 
cable. Pain and tenderness in the abdomen, arising from chronic, 
i. e., tuberculous peritonitis, may occur at any period, though it is 
sometimes itself the older disease, and, with its treatment, must be 
considered hereafter. 

We have before spoken of the pneumonic phthisis, in which the 
excavation of the lung appears to be brought about by the softening 
of those parts of the organ which had been the subject of pneumonic 
consolidation ; this form of the affection — the pneumonic phthisis of 
Dr. Addison — appears to be that alluded to by Dr. Graves, under the 
term scrofulous pneumonia. There is again another form of disease 
which is closely allied to phthisis, and that is the chronic bronchitis, 
with profuse puriform expectoration, of which also we have before 
spoken — probably the- scrofulous bronchitis of Graves. These affec- 
tions are to be met with — (1) In those who have inherited no ten- 
dency to tuberculosis, but whose constitutions have been impaired by 
exposure, illness, or irregularities, or by repeated attacks of the acute 
forms of the above diseases. (2) In persons of strumous constitu- 
tions, who have escaped the dangers of phthisis in early life, but 
in whom the tendency again manifests itself, though in this altered 
shape, when their strength has become impaired by age. These 
forms of disease constitute, in fact, the phthisis of impaired constitu- 
tions and of advanced life. The treatment of these affections must 
be conducted upon the principles already laid down when speaking 
of pneumonia and bronchitis. 

* (39) R. Pulv. Rhei, gr. xv. 

Pulv. Cretse co. c. Opio, gr. x. Misce. 
Ft. Pulv. ; to be taken in any suitable vehicle. 

f (40) R. Acid. Nit. dil. 7^ xij. 
Tinct. Opii, n^ v. — x. 
Syrupi 3 i. 

Aq. Cinnam. g x. Misce. / 

Ft. haust. ; to be taken every sixth or fourth hour. 



DISEASES OF THE HEART. 255 



'XIV. 
DISEASES OF THE HEAET AND ITS APPENDAGES. 

Like all serous membranes, the capsule of the heart is liable to 
inflammation from various causes. This inflammation constitutes 
pericarditis. Pericarditis may be acute or chronic; it maybe idio- 
. pathic, that is to say, arising to all appearance spontaneously, or 
excited only by the ordinary causes of inflammation ; it may also be 
secondary, that is, the consequence of some anterior disease affecting 
either the whole system or particular organs. 

Acute pericarditis in its perfect form, passes through the stages of 
engorgement or congestion, effusion of lymph or serum, absorption, 
and adhesion. 

In the first of these stages, the surface of the membrane is gene- 
rally dryer than in health, and if the disease be arrested in this stage 
(i. e. if resolution takes place), no permanent effect is produced. In 
the second stage, the effusion may assume various forms, according 
as the fibrinous lymph, molecular lymph, or serum predominate. 
When the effusion consists almost entirely of fibrinous lymph, it is 
deposited in layers of varying thickness, which often speedily form 
a bond of union between the cardiac and reflected surfaces of this 
membrane ; though, when very thin, they remain in flakes upon its 
surface. When the molecular lymph predominates, the solid deposit 
will be less firm, and there will be (especially if the powers of the 
system be enfeebled) a tendency to puriform degeneration, pus being 
sometimes formed in the cavity of the membrane, which produces 
speedy death by its pressure on the heart; a large quantity of pus 
being found in the cavity after death, and the surface of the heart 
covered by soft villous lymph. It more commonly happens, how- 
ever, that an intermediate condition exists, in which the effusion 
being but imperfectly plastic, the solid matter is softer than the true 
fibrinous lymph, and after death the apposed surfaces of the pericar- 
dium are found to have been but feebly agglutinated, and present, 
when separated, a villous appearance ; it is this form of effusion, pro- 
bably, which has been not unaptly compared by Dr. Watson to the 
rough sides of pieces of tripe which may be seen in butcher's shops. 
Sometimes, again, the serum is poured out in large quantities, and if 
not speedily reabsorbed, is fatal in the same manner as the puriform 
effusion ; it is, however, much more susceptible of absorption, as 
well as of much more frequent occurrence. 

The next stage is the absorption of fluid ; this often takes place very 
rapidly, or, what is the same thing, the quantity poured out having 
been very small, the lymph is left either giving rise to a greater or 
less extent of adhesion, merely covering portions of the membrane. 

The next step in the history of ordinary inflammatory exudations 
is, the organization of the lymph ; and when this takes place without 



256 PERICARDITIS. 

connecting the two surfaces of the pericardium, the membrane be- 
comes in parts roughened by layers of areolar tissue. When the 
two surfaces are glued together, the organisation of the effused 
lymph takes place with greater or less rapidity, and different effects 
may be produced on the surface of the heart. There may be simple 
adhesion, with scarce any areolar tissue between the surfaces, an 
occurrence which has no doubt given rise to the fables of the peri- 
cardium having been found wanting altogether ; or, there may be 
only partial adhesion, or, the fibrinous lymph may have been so 
thick, that, by the contraction which accompanies its organisation, it, 
in a measure, strangulates the heart, and greatly embarrasses the 
circulation. 

It has been a matter of some doubt, whether the fibrinous effusion 
is ever removed by absorption ; that it sometimes is, though after a 
long interval, and probably through the intervention of fatty de- 
generation, has been shown by Professor Paget. 

The general symptoms of pericarditis, independently of its physical 
signs, are alone insufficient for the purposes of diagnosis ; but so, in 
some instances, are the physical signs themselves, and therefore 
neither one or the other are to be disregarded. 

The disease sometimes comes on insidiously ; often, in the course 
of an ordinary attack of acute rheumatism. There may have been no 
symptoms to mark the origin of pericarditis, yet, upon careful ex- 
amination, there may be found evidence of changes which would 
imply a duration of some days : there may have been rigors, but 
these are by no means necessary ; and the pain, in the region of the 
heart, though a symptom upon which much stress has been laid by 
several authors, is so often absent when the inflammation is confined 
to the pericardium, that it may well be questioned, whether, in all 
cases in which it occurs, it is not an accident produced by the pleuritis 
which so frequently attends this disease, rather than one of its essential 
symptoms. 

When in pericarditis there is pain in the region of the heart, it is 
generally increased by pressure made upwards against the diaphragm 
by means of the fingers placed under the margin of the ribs ; often 
there is also a sense of weight or stiffness about the left shoulder, 
extending down the arm to the elbow or wrist. 

Though there may be no pain, there are always, in acute pericar- 
ditis, great distress and anxiety, which are plainly expressed in the 
shrunken features and contracted countenance: the position too is 
often peculiar ; the patient sitting up in his bed with the shoulders 
bent forwards, and the elbows resting upon the knees, or some other 
support. Sometimes he will recline upon the left elbow, or against 
some support placed by the bedside, as he rarely, if ever, lies fairly 
upon that side, or, indeed, upon either, though he may upon his 
back. 

The occasional presence of orthopnoea has induced some authors 
to state that its occurrence is a sign of effusion into the paricardium ; 
this is certainly not the case, as it is often wanting when there is 
effusion, and as often present, and indeed urgent, when there can be 



ITS PHYSICAL SIGNS. 257 

none ; it probably depends more upon the situation and extent of the 
inflammation than upon any other circumstance. As a general rule, the 
descent of the diaphragm increases the uneasiness, and therefore the 
patient endeavours to place himself in the position most likely to 
keep it at rest. This is sometimes the case to such an extent, that a 
patient has been known to tie a belt or bandage round the waist, 
finding relief by restraining the motion of the diaphragm in this 
manner; the respiration is almost always hurried, and the alse nasa 
expand perceptibly ; the number of respirations, too, is increased in 
a greater proportion than the frequency of the pulse. 

The free motion of the heart is no doubt in some degree interfered 
with, and so far we have the Icesa partis functio to aid us in our diag- 
nosis ; but as there are so many other disorders that render the 
heart's action hurried or irregular, no great reliance is to be placed 
upon this symptom. As a general rule, however, the pulse is frequent, 
sometimes full and hard at the commencement, but becoming, as the 
disease advances, feeble, sometimes wiry, and often unequal both in 
force and rhythm ; the frequency of the pulse is also very liable to 
great and sudden variations, especially upon change of posture, some- 
times even from the slightest movement ; the tongue is in the more 
acute and sthenic cases generally covered with a white fur, but it 
presents no characteristic appearance ; there is often, especially in 
rheumatic cases, a profuse perspiration, and the urine is generally 
scanty, high-coloured, and loaded with urates. 

When effusion has taken place, the action of the heart becomes 
heaving, the dyspnoea urgent, and the pulse very feeble and ir- 
regular. 

Another important, though not very common symptom of peri- 
carditis, and one that may occur at any period of the disease, is 
delirium, which is sometimes of a furious character; this distressing 
complication is most liable to arise when the cardiac inflammation 
supervenes upon an attack of acute rheumatism. 

The topical signs of pericarditis are, in the majority of cases, 
pretty distinct, though in some rarer ones they are either altogether 
wanting, or so feebly marked that the disease is not easy of de- 
tection. 

In nearly all cases of this disease, and through all its stages, the 
mobility of the walls of the chest, over the region of the heart, is 
obviously diminished: in the greater number, the breathing is 
thoracic, for the reasons already stated; but in some few, in which 
the inflammation affects mainly or entirely the base of the heart, it 
may be abdominal. 

In the first stage, or that of engorgement, the irritability of the 
organ being increased, the impulse is most obvious to the eye ; and 
when the hand is placed over the heart, this impulse is felt to be 
stronger, as well as sharper than in health ; the area of the precordial 
dulness upon percussion is not increased ; auscultation gives a faint 
friction-sound generally with the first beat, but this is by no means 
constant. 

When the exudation of lymph has commenced, there is not un- 

17 



258 ENDOCARDITIS. 

commonly a thrill to be felt over the region of the heart, and when 
the lymph effused is very thick, there is increased precordial dul- 
ness; but the characteristic sisrn of this stasre is the friction-sound, 
which is produced by the attrition of the surfaces of the pericardium 
roughened by fresh lymph. This sound is heard with most distinct- 
ness when the lymph which produces it is situated near the base of 
the heart, and it then commonly accompanies both sounds, constitut- 
ing the to-and-fro murmur, which can often be traced to the origin 
of the aorta, but no higher. When the friction-sound is produced 
more towards the apex of the heart, it is not so constantly double, 
and generally follows immediately upon the first sound, so as to 
appear like a continuation of it ; it is generally soft in its character, 
approaching to the bellows murmur, though sometimes it has more 
of a harsh or rasping tone. It should be remembered that the sounds 
produced by the attrition of the surface of the pericardium are in 
themselves morbid or preternatural; and not, as may be the case 
with valvular murmurs, modifications of the natural sounds ; and, 
therefore, although they may be obscure, they do not, as in the case 
of the latter, supersede them. The natural sounds are therefore still 
present, though it may be difficult at all times to separate them from 
the new ones introduced by disease. 

Allusion has alreadv been made to the occasional absence or 
obscurity of the stethoscopic sounds of pericarditis, and this remark 
is, perhaps, more applicable to the friction sounds, of the stage of 
exudation; for cases certainly have occurred in which effusion of 
fresh lymph has been found after death, and in which no friction-sound 
could be detected during life, though sought for at so short a period 
before death as to preclude the possibility of effused serum having 
prevented the friction, and having been subsequently absorbed. In 
such cases the lymph is of the soft villous character, and the powers 
of the system and action of the heart have been feeble. 

In the case of effusion of fluid, the area of the precordial dulness 
is considerably increased, and occupies a triangular space correspond- 
ing to the situation of the pericardium ; the impulse of the heart 
though feeble is diffused and heaving, and the rhythm sometimes 
irregular (the pulse at the wrist being very feeble and often inter- 
mitting) : an undulating motion may also be sometimes felt by the 
hand, and some authors mention a protrusion of the intercostal spaces 
in the precordial region; though it is doubtful if this ever occurs 
independently of pleuritis. The apex of the heart is raised higher 
than its natural position. The sounds are distinct and feeble; in 
most cases the friction-sounds which had been previously heard are 
observed to have ceased ; and where the process of their obliteration 
has been carefully watched, they will be found to have disappeared 
from below upwards. 

When absorption of the effused fluid takes place, the friction- 
sounds gradually return, extending from the base of the heart 
downwards towards its apex, and the charcteristic signs of effusion 
gradually disappear. When adhesion is established the friction- 
sounds are much diminished, and in some cases again disappear 



FIRST STAGE. 259 

altogether, but there often remains a rolling and trembling motion 
of the heart. The consideration of further changes in the products 
of the inflammation belong more to the subject of chronic inflamma- 
tion of the pericardium. 

The internal, like the external lining of the heart, is liable to 
inflammation, constituting endocarditis, which, like pericarditis, may 
be either acute or chronic, primary or secondary, and is liable to be 
excited by the same causes. 

The anatomical changes of endocarditis are, at the commencement, 
engorgement, with more or less consequent tumefaction of the mem- 
brane and subjacent tissues, next, effusion of lymph or pure fibrine 
upon its surface or immediately beneath it, subsequently, thickening, 
granulation, contraction, and puckering, sometimes adhesion, softening 
and laceration ; the functional effect throughout is increased excita- 
bility of the organ, with impaired action of its valvular apparatus. 

As the effect of the functional derangement, we have palpitation 
and uneasiness at the region of the heart, but not necessarily pain or 
tenderness in the praecordial region. As the effect of the anatomical 
changes, we have more or less turgescence of the organ itself, with 
alterations in the sounds accompanying its action, and disturbances 
in the current of the blood. 

The constitutional symptoms of endocarditis differ but little from 
those of pericarditis. There is much the same anxiety of countenance, 
but less dyspnoea; the attitude is less constrained, though the patient 
generally lies on his back ; and sometimes there is considerable rest- 
lessness : the skin is hot, but not remarkably so ; the pulse quick, 
sometimes unequal or irregular, not intermittent at the commence- 
ment of the disease, though the late Dr. J. Taylor stated that it was 
slow at that period, a remark which applies only to its very beginning. 

The anatomical changes in the heart and the valves, produce cor- 
responding alterations in the physical signs which accompany the 
movements of this organ, and in its action as an hydraulic machine ; 
in which latter we include the systemic and pulmonic circulations. 
These changes will best be understood by tracing them from the 
heart through the system in the different stages of the disease. 

In the first stage, — that of hyperemia or engorgement, — we have 
more or less turgescence of the organ itself, and this is attended by 
some increase in the area of the precordial dulness ; the impulse of 
the heart is, at the same time, rather duller and more forcible than in 
health, as well as sharper or quicker. There being as yet merely 
turgescence of the valves, we have no great amount of imperfection 
in their action, and, therefore, although the sounds accompanying it 
may be modified, the current of the circulation is not much disturbed ; 
accordingly, a valvular murmur may be heard at this period. This 
murmur, which accompanies the first or systolic beat of the heart, is 
most distinct in the mid-sternum, and may be traced along the course 
of the aorta nearly to the top of the first bone of the sternum ; it is 
produced by the turgescence of the aortic valves, causing them to 
obstruct the current through the aortic orifice more than they do in 
health. There is also frequently a murmur to be heard more towards 



260 ENDOCARDITIS. 

the axilla in the situation of the mitral valve, also accompanying the 
first sound. This murmur is generally of the soft blowing character, 
and is by some authors referred to regurgitation through the mitral 
valve ; the difficulty of this explanation lies in the want of proof that 
such regurgitation does take place, neither is there any reason for 
supposing it, unless it be owing to imperfect closure of the valve, 
arising from the action of the columnae carnae being impaired by the 
inflammation of their investing membrane. Others have supposed it 
to arise from the ventricular surface of the right curtain of the swol- 
len valve disturbing the current of blood towards the aorta, though, 
if this were true, the murmur would be traceable along the ascending 
aorta, which it is not. May not the explanation of this murmur, 
which is a modification of the first sound, be found in the considera- 
tion that this sound is a complex phenomenon, in the production of 
which the closure of the auriculo-ventricular valves is not the sole 
agent, whilst an important one in producing it, namely, the muscular 
contraction, may be considerably affected? After all, it is probable 
that the only murmur properly belonging to the first stage of endo- 
carditis is the- soft systolic aortic murmur described above. The 
pulse, as before mentioned, is quick (except, perhaps, at the very 
commencement of the attack), and its sharpness is somewhat increased, 
but we have as yet none of the conditions of the pulse characteristic 
of imperfect action of the valves (p. 69) ; in fact, the absence of such 
conditions may be cited as additional evidence against the murmur 
above referred to being produced by mitral regurgitation. 

In the second stage, or that of exudation, the lymph may exude 
either upon the free surface of the endocardium or underneath it; in 
the former case it is often thrown out upon the ventricular surfaces 
of the aortic sigmoids, rarely upon those of the pulmonic: being soft, 
it probably yields to the pressure where the surfaces are apposed in 
closing the orifice, and, accumulating along the edge of those sur- 
faces, forms a sort of fringe along the margin of the two crescent- 
shaped segments which constitute the surfaces of apposition; that is 
to say, along the crescentic margins of the opaque scutiform portion 
of the valve, or else along the free margin of the valve itself, in the 
manner described by Dr. "Watson. The same thing may occur along 
the margins of the apposed surfaces of the mitral valve, and some- 
times of the bicuspid, though the same exact regularity of arrange- 
ment is not observed. These fringes of lymph generally increase, 
either by fresh exudations, or by the deposition upon them of the 
fibrine from the blood itself, so as to form excrescences of sufficient 
size to disturb the current passing through the orifices of the heart, 
and sometimes to prevent the accurate closure of the valves them- 
selves. Similar deposits may also take place upon other parts of the 
internal surface of the heart, as upon the walls of the cavities, or 
upon the surfaces of the fleshy columns, or amongst the chordse ten- 
dinge. It is also a possible, though not very frequent occurrence, that 
these deposits of fibrine may become detached and form loose coagula 
in one of the cavities, generally in the left ventricle ; and these are 
sometimes of sufficient size to cause sudden death by obstructing the 



SECOND STAGE. 261 

orifice, or, undergoing degeneration, to set up pyhaemia and its dis- 
astrous consequences. 

When the lymph exudes underneath the endocardium, there will 
ensue an opacity of the membrane where it lines the cavities, and 
when between the layers which form the valves, the latter will, in 
this stage of the disease, be swollen and thickened ; thus they may, 
more than in health, encroach upon the space allowed for the current 
of the blood, and by their becoming less flexible the freedom of their 
action may be impeded. The signs by which these changes may be 
recognized will be best understood by considering their effects upon 
the action of the heart, and the current of the blood. When there is 
exudation \ipon the surface, or between the layers of the aortic valves, 
there will be more or less narrowing of the orifice, and consequently, 
upon auscultation, there will be heard the systolic blowing murmur, 
traceable from the situation of the aortic valves along the course of 
the artery, as in the first stage of the disease. But it may happen, 
besides, that the closure of the valve is imperfect, and in this case a 
murmur, produced by a reflux of blood through the orifice, will be 
heard in the same situation, but accompanying the second sound. In 
this stage of endocarditis affecting the aortic orifice and its valves, 
there may be a double, or, as it has been called, a see-saw murmur. 
This is not by any means a constant effect, as the murmur may re- 
main a single one in this stage, and even in the next, but when it is 
present it proves that the disease has gone beyond the first stage. 

Lesion of these valves has, as has been pointed out (p. 69), a cha- 
racteristic influence upon the pulse at the wrist. When there is 
simply obstruction, the pulse will be rather sharp, compressible, and 
of small volume compared to the impulse of the heart ; when, how- 
ever, there is regurgitation through the sigmoid valves, there is the 
splashing or " water-hammer" pulse. 

It has been remarked, and with much reason, by Dr. Chevers (on 
Diseases of the Heart, p. 17), that it is important to distinguish be- 
tween effusion upon the surface and between the layers of the valves. 
When there is a very harsh or musical murmur with the first sound, 
but none (indicating regurgitation) with the second, the probability 
is in favour of deposit upon the surface of the valve, particularly if 
this occur early in the disease, and in a subject of previously good 
health. 

When the exudation takes place upon the surface of the mitral 
valve, or between its layers, there may occur one or both of two 
things, the current from the auricle into the ventricle may be ob- 
structed, or there may be regurgitation into the auricle. It is very 
doubtful whether the former occurrence ever produces a murmur, 
though some authors have described such ; if it do occur, it must 
just precede the natural first sound ; it is, however, to say the least, 
very rare. When there is regurgitation, there is a murmur accom- 
panying the first sound, and heard more distinctly towards the axilla ; 
but for the reasons already adduced, there is much more obscurity 
attaching to the sounds ascribed to this valve, than to those of the 
sigmoids. The pulse, however, affords us great assistance, especially 



262 ENDOCAKDITIS. 

if there be no disease of the aortic valves, which would, of course, 
materially disguise any character that it would receive from the con- 
dition of the mitral ; but where these are free, the pulse at the wrist 
will be either very small and intermittent or both, the latter condi- 
tion belonging more especially to those cases in which the orifice is 
contracted. And even in cases where there is obvious disease of 
the aortic valves, the pulse will be much smaller and less splashing 
than it would have been had the mitral disease not been present also. 

Throughout this stage the constitutional signs of endocardial 
inflammation continue as before. 

In the more advanced stage of the disease are found the changes 
which ordinarily take place in inflammatory exudations, producing 
in the valves and orifices of the heart thickening, granulation, con- 
traction, puckering, adhesion, and, sometimes, softening and lacera- 
tion. These processes seldom occur singly; and therefore, we 
commonly find the characteristic signs of two or more of them occur- 
ring at the same time : to begin with the aortic valves — there may 
be thickening of the valves, and often with this there will be granu- 
lations or warty excrescences on their surface, arising from the orga- 
nisation of the lymph which has been deposited as already described 
(p. 260) ; and to these may be added fresh deposits of fibrine from 
the blood. There will then be increased impulse of the heart, whilst 
the pulse at the wrist will not be proportionately strong, and a hoarse 
systolic murmur traceable along the ascending aorta : but in addition 
to this, the effect of the granulations may be to impair the closure of 
the valves, and cause, in addition to the above signs, a diastolic 
murmur in the same situation, with a splashing or " water-hammer" 
pulse. 

Again, there may be adhesion between the contiguous extremities 
or angles of two valves, and with it a tearing away, from their inser- 
tions, of the angle, close to which the adhesion takes place ; so that 
the two valves are formed into one imperfect One ; or, owing to the 
contraction of the fibrinous lymph effused between their layers, the 
valves may become puckered. In either case, there may be present 
the signs of obstruction combined with those of regurgitation, in a 
much more marked degree than in the earlier stages of the disease. 

The same changes may occur in the mitral valve, from exudation 
upon the surface of its curtains, or between the folds of endocardium 
of which they are formed ; and we then find the signs of obstruction 
and regurgitation the same as when the valves are thickened or ob- 
structed in the commencement of the exudation ; but, as in the case 
of the aortic, in a more marked degree, both in the sounds of the 
heart and in the character of the pulse ; though it must still be borne 
in mind that there is a greater obscurity in the diagnosis of disease 
of the mitral, than of that of the aortic valves, arising, as has been 
pointed out, from the complicated character of the first sound, and 
from the effect upon the pulse, of disease of the former valve, being 
liable to be modified by that of the latter, as well as simulated by 
other conditions of the circulation. 

There is another effect of inflammation upon the mitral valves 



CARDITIS — CAUSES. 263 

which deserves notice, though not of very frequent occurrence, 
namely, — softening and consequent laceration of the chordae tendi- 
neae. After death several of these may be found separated, and the 
extremities shrivelled up upon the free edge of the valve, and covered 
with clusters of vegetations. The necessary and immediate conse- 
quence of this accident is considerable regurgitation into the left 
auricle, diminished supply to the systemic circulation, and great 
engorgement of the lungs, causing imminent danger from the com- 
bined effects of syncope and apnoea. 

The further changes which occur in the lining membrane and 
orifices of the heart, and the effects upon the extreme circulation and 
other parts of the system, belong more appropriately to chronic 
endocarditis and its consequences. 

The pathological changes, as well as the immediate effects and 
symptoms of pericarditis and of endocarditis, have been separately 
described to enable the student to analyze more accurately the vari- 
ous cases which present themselves in practice rather than with the 
view of describing diseases which often occur in a simple and uncom- 
plicated form, as it is far more common to meet with the two affec- 
tions combined than with either singly. This will be apparent by 
considering the causes of pericarditis and endocarditis. 

Like pericarditis, endocarditis may arise, to all appearance, sponta- 
neously and as a primary affection, depending upon no assignable 
cause beyond those of ordinary inflammation ; but like the former, it 
is more commonly the effect of some antecedent disease. 

In estimating the frequency of primary or idiopathic pericarditis, 
as well as endocarditis, some allowance must be made for the chance 
of both one and the other being overlooked, especially when they 
do not terminate fatally; still neither of them is probably of frequent 
occurrence. Of the idiopathic inflammations of the serous mem- 
branes, those affecting the heart are less frequent than idiopathic 
pleuritis or arachnitis, but more so than idiopathic peritonitis ; and 
as regards their frequency relatively to each other, idiopathic peri- 
carditis is more common than idiopathic endocarditis. 

Both these diseases are, however, almost universally blood dis- 
eases, that is to say, arising from some morbid poison or — from 
retained secretion in the blood. 

Of the former class of causes, by far the most frequent is acute 
rheumatism. So much is this the case that we may safely affirm 
that by far the greater number of cases of acute pericarditis, and also 
of acute endocarditis, are rheumatic. 

Next to acute rheumatism as a specific disease, acting as a cause of 
acute pericarditis or endocarditis, is influenza, and next to it, but 
far less frequent as a cause of cardiac inflammation, is scarlatina ; 
and it is probable that all the eruptive fevers may occasionally 
induce inflammation of these membranes. 

Of the latter class of causes, namely, retained secretion, by far the 
most common is uraemia, from disease of the kidneys, which next to 
rheumatism is the most frequent of all the causes of acute cardiac 



264 CAKDITIS — CAUSES. 

inflammation, and is the most frequent cause of subacute inflamma- 
tory action terminating in organic disease. The same thing may 
occur, though much more rarely, from retained biliary secretion ; 
and it is not improbable that a large proportion of cases of so-called 
idiopathic inflammation of either surface of the heart arise from a 
similar condition of the blood, induced by repression of the cutaneous 
exhalation. 

Such being the causes common to both pericarditis and endocarditis, 
it might be expected, as, in fact, is ordinarily the case in practice, 
that the one will almost always be more or less complicated with the 
other; especially in the more common case of their occurring as 
secondary diseases; and therefore we may speak of them under the 
common term of carditis as regards their general diagnosis, prognosis, 
and treatment. 

The diagnosis of pericarditis is only to be considered certain, when 
we have the characteristic friction-sound, of the rather crackling char- 
acter, which belongs to recent exudation; and this is most distinctly 
heard when the inflammation involves the base of the heart, and con- 
sequently the sound is double. It is very true, as observed by Dr. 
Walshe, that this friction-sound may be mistaken for other things ; 
but it must also be remembered that the sound may be wanting 
under certain conditions; and then we are left to conjecture the pre- 
sence of the disease by the previous history, the character of the 
pulse, the position of the patient, and the diminished mobility of the 
lower ribs and diaphragm ; though nearly the same symptoms would 
be presented by pleurisy on the left side, confined to the diaphragm. 
Fortunately, in acute stages of either disease, the diagnosis between 
them would be of no practical importance. The diagnosis between 
pericarditis with a friction-sound, and pleuritis of that part of the 
membrane which overlaps the heart, will generally be effected by 
observing the difference between the cardiac and respiratory rhythm ; 
but there is one source of fallacy, in pleuritic friction-sound some- 
times effecting a cardiac rhythm : when this is the case, however, the 
sound is not to be heard over so large an extent of the cardiac region, 
but is more confined to the edge of that region; the pleural sound 
too is not heard with every beat of the heart, especially when the 
patient holds his breath * 

The diagnosis of endocarditis, before it has produced the charac- 
teristic sounds of valvular disease, is perhaps more doubtful than 
that of pericarditis ; though where these are absent the probability is 
in favour of the existence of the former disease rather than the latter, 
particularly if the patient do not exhibit the characteristic attitude 
and countenance of pericarditis. 

There is another form of disease which presents many of the symp- 
toms of both pericarditis and endocarditis, namely, pleuritis on the 
left side, and nearly confined to that portion of the membrane which 
is connected with the diaphragm. The diagnosis will, however, soon 
become clear in the majority of cases, either by the appearance of the 

* Drs. Addison and Walshe. 



CAEDITIS — MODES OF DEATH. 265 

friction-sounds or murmurs ; or, by their continued absence, render- 
ing it highly probable that there is no cardiac lesion. It is important 
to bear this distinction in mind, in order to be able more clearly to 
foresee the subsequent progress of the disease ; though, as regards the 
immediate treatment, it is of no great practical moment. 

Neither pericarditis nor endocarditis, nor the two combined in the 
more common disease which, for the sake of brevity, we term carditis, 
is so often fatal in the acute stage, as by the remote effects to which 
they very frequently lead, the consideration of which belongs more 
properly to chronic carditis. Death does, however, not very rarely 
occur in pericarditis, either from the sudden and rapid effusion of 
serum or puriform fluid between the surfaces of the membrane, 
which by its pressure upon the heart produces death from syncope, 
particularly in pericarditis from diseased kidney and uraemia; or the 
disease may terminate by sinking or gradual syncope from the 
depressing effect upon the heart's action, of the continuance of the 
inflammation without any effusion sufficient to account for such a 
result. This mode of death may also occur in the manner just men- 
tioned, from endocarditis, as may also sudden syncope from the 
sudden occlusion of one of the orifices of the left side of the heart, 
by a coagulum of fibrine, which has formed about the lymph effused 
upon- the inflamed portion of endocardium, and become detached 
from thence by the current of the blood. 

Cardiac inflammation may also prove fatal by exhaustion conse- 
quent upon sudden and often violent delirium supervening in the 
course of the disease; sometimes, too, when it appears to be sub- 
siding, and this without a trace of any lesion being found within the 
cranium. This occurrence is most to be apprehended in rheumatic 
carditis. 

The treatment of carditis will be much the same whether it affect 
the external or internal surface of the heart. The great principle of 
keeping the part affected in perfect rest in all acute inflammations, 
cannot be applied, except to a very limited extent ; still much may 
be done towards removing all causes of excitement of the circulation, 
and something towards producing a directly sedative effect upon the 
heart. "With this end, in all cases of cardiac inflammation it is neces- 
sary not only to confine the patient strictly to his bed. but to enjoin 
the most careful avoidance of every movement that can possibly be 
prevented, a precaution which in cases of this kind is too often 
neglected, or, rather, not enforced with the earnestness it deserves. 

Another important preventive is the removal, as far as lies in our 
power, of every mental excitement. Upon this account, as well as 
of the physical exertion which attends it, no conversation should be 
allowed; not only should the diet be most strictly antiphlogistic, in 
the commencement of all acute cases occurring in any but the most 
asthenic conditions of the system ; but we should also endeavour, by 
regulating the quantity of fluid taken, and by maintaining regular 
and copious discharges from the bowels, the kidneys, and the skin, 
to render the volume of the circulation as moderate and uniform as 
possible. 



266 CARDITIS. 

As regards more direct remedial measures, the first question which 
suggests itself is the expediency of general bleeding. The expecta- 
tion of thoroughly annihilating an attack of carditis by free and 
repeated venesection, as recommended by M. Bouilland, has been 
long abandoned in this country ; both on account of the improbability 
that where fibrinous exudation has taken place it can be speedily 
removed, and also because bleeding pushed to such an extent as 
greatly to retard the movement of the circulation is not the most 
likely means of effecting this result. Still it is not impossible, as 
remarked by Dr. Watson, that, if the general symptoms teach that 
pericarditis exists, but no attrition-sound is to be heard, we may 
hope to arrest the disease by a full and copious bleeding. And the 
same applies to endocarditis, with the qualification that there may 
exist a faint valvular murmur from the mere vascular turgescence of 
the valves before any truly inflammatory exudation has taken place. 
As a general rule, the venesection is admissible and desirable in the 
very commencement of inflammation of either surface of the heart, 
though care must be taken that the absence of the pericardial friction 
is not attributed to the early period of the disease, when, in reality, 
it is the effect of the exudation being of the flocculent, almost puri- 
form character, together with the very feeble action of the heart, 
both resulting from an asthenic condition. 

Unless, however, the indications of bleeding are decided, a safer 
plan, and not less beneficial, will be the abstraction of a moderate 
quantity of blood from the region of the heart by cupping or leeches 
(the former being generally to be preferred): this remedy, though it 
cannot annihilate the disease after the second stage has been estab- 
lished, will do much towards checking its further progress; and the 
measure may be repeated without danger to the patient. The next 
object is to get the patient under the influence of mercury, which 
will be best affected by the combination of calomel, antimony, and 
opium already recommended (F. 3 & 4) ; the antimony will also fulfil 
the important indication of depressing the force of the heart's action. 

When in the course of the disease, or even after its apparent sub- 
sidence, effusion appears to be taking place rapidly into the pericar- 
dium, a large blister applied to the region of the heart will often 
have the effect of arresting it. 

It has been observed above, that carditis may at almost any period 
terminate by rapid sinking, and then it may sometimes become neces- 
sary to have recourse to stimulants. When the pulse becomes very 
feeble, the skin cold and clammy, and there are general signs of 
prostration, especially in an advanced stage of the disease, ammonia, 
wine, or even brandy may be administered, even although from the 
probable continuance of the inflammation it is necessary still to repeat 
the calomel. 

The above remarks apply to the treatment of carditis generally, 
and more particularly to its simplest, though rarest form, namely, the 
idiopathic. When, however, it occurs in its more common form of 
a secondary disease, the treatment must be regulated in a great mea- 
sure by the primary one. 



TREATMENT. 267 

It has been of late a question amongst physicians whether rheu- 
matic carditis should be treated as a common inflammation, or by 
the means which are found most applicable to the specific one. Till 
very lately the former has been the plan most generally followed ; 
and perhaps in an acute inflammation, attacking so important a part, 
it is hardly safe to wait till the secondary disease can be overcome 
by eradicating the primary one ; it becomes, therefore, necessary to 
direct our treatment immediately to the latter; though it will be 
most reasonable and generally most successful to select the remedies 
with some reference to the former. The lemon juice recommended 
by Dr. Rees, and which is undoubtedly efficacious in acute rheuma- 
tism of the joints, is hardly admissible at the same time with the 
calomel, and therefore it is best to use some other remedy of known 
efficacy in rheumatic inflammation which can be administered at the 
same time with the mercurial. When either surface of the heart 
becomes implicated in the course of an attack of acute rheumatism, 
apply twelve leeches to the region of the heart, or what is better, let 
about eight ounces of blood be taken from thence by cupping, and 
let the patient take the calomel, antimony, and opium ; two grains of 
the former, one of the opium, and a quarter of a grain of the anti- 
mony being given to an adult three times a day, and in the intervals 
let him take the acetate and nitrate of potass (F. 11). 

When the pulse becomes less sharp a blister may be applied to the 
region of the heart ; and as soon as there is the least effect produced 
upon the gums by the mercury, the quantity must be diminished, 
generally to about one grain night and morning, the opium and anti- 
mony being administered with it, or else from five to ten grains of 
the compound ipecacuanha powder, and the acetate and nitrate of 
potass with about half a drachm of nitric asther, and the same quantity 
of tincture of hyoscyamus. Digitalis has been recommended on 
account of its lowering the action of the heart; but in a disease 
which may terminate suddenly by syncope, it cannot be considered 
a safe remedv. Colchicum is also used in rheumatic inflammation of 
the heart ; but it is not altogether free from the same objections as 
digitalis, and the sedative effect of the saline above recommended 
will in a great measure fulfil the same indication. When, however, 
a purgative is required, the addition of from twenty to thirty minims 
of the compound tincture to a senna draught is admissible. 

It sometimes happens that when the patient appears to be going 
on favourably, sudden effusion takes place into the pericardium: 
under such circumstances the application of large blisters will, as in 
the case of primary pericarditis, often speedily effect its absorption. 

When the disease appears to be assuming a subacute form, in 
which case there is often more or less of subacute rheumatism affect- 
ing the joints, the iodide of potassium with liquor potassa? may be 
administered in infusion of bark, and counter-irritation must be 
continued by means either of repeated blisters, or the tartar-emetic 
ointment. The tendency to syncope will sometimes be so great as 
apparently to require stimulants: these, however, should be cautiously 
given, the safest, perhaps, being about ten or fifteen minims of sp. 



268 CARDITIS. 

seth. co., with, twenty of sp. amnion, aromat. The sudden invasion 
of delirium is a very alarming symptom, and, if not checked, the 
excitement sometimes terminates by death from exhaustion: this 
delirium is not generally to be regarded as arising from active 
inflammation of the brain or its membranes, but appears to be a 
secondary effect of the cardiac inflammation, occurring when the 
nervous system is in an asthenic condition, and therefore it is best 
met by opiates and stimulants. There are, no doubt, exceptions to 
this rule, and therefore caution is requisite in the exhibition of these 
remedies ; and if there be dry skin, scanty urine, or contracted pupil, 
calomel should be combined with the opium, or when the signs of 
active irritation of the brain are strongly marked, the opium should 
be withheld, and the hyoscyamus, camphor, and calomel administered 
(F. 41).* 

Another class of cases of inflammation of one or both surfaces of 
the heart are those which present themselves in connection with 
specific febrile diseases. Of these, perhaps the most common are 
those occurring in influenza. Scarlatina also is sometimes followed 
by inflammation of the heart, and the same thing may occur as an 
effect of small-pox, typhus, or any other specific fever. 

When we have to do with pericarditis or endocarditis occurring as 
a complication of influenza, the leading principle in the treatment of 
the primary disease, namely, its intolerance of loss of blood, must be 
kept steadily in view ; even the application of any considerable 
number of leeches will sometimes cause furious delirium, and if the 
the abstraction of blood is attended by no apparent ill effects, or even 
when the inflammation appears to be mitigated, the amendment is, 
in most instances, only temporary (pp. 89-90). In such cases, a blister 
should be applied to the region of the heart, calomel administered, 
in combination with antimony and opium, so as to induce a decided 
mercurial action, and in the intervals, acetate of ammonia, to which 
should be added an excess of the carbonate, as soon as symptoms of 
exhaustion supervene, which they commonly will in all inflammatory 
complications of influenza ; and, as a general rule, it will be safer to 
anticipate them. Wine and aether may also become necessary in 
such cases. Nearly the same rules apply to the treatment of cardiac 
inflammation occurring as an effect of the scarlatinous poison, though 
probably the necessity for stimulants will not present itself so early. 
When urea or bile are retained in the system, we have, especially in 
the case of the former, a liability to inflammation of the pericardium 
and endocardium as of all serous membranes. In carditis from 
uraemia mercury must be sparingly used ; and therefore when the 
disease arises from this cause, we must have recourse to local bleeding 
by cupping or leeches, the former being generally to be preferred, 
blisters, purgatives, and diuretics, the mercury being administered in 

* (41) R. Hydrarg. chlorid. 

Camphorse, aa gr. j. 
Ext. Hyos^yami, gr. iij. M. 
Ft. Pil. ; to be taken every third or fourth hour. 



TREATMENT. 269 

small quantities, and immediately withdrawn upon the first appear- 
ance of its specific effects. 

It may be observed, before quitting the subject of acute inflamma- 
tion of the surfaces of the heart, that the term carditis has been by 
some authors restricted to inflammation of the substance, or muscular 
structure of the organ, a disease which, though it may be theoretically 
possible, is one of which we have no experience in its simple form. 
It is indeed highly probable that in the greater number of instances 
of inflammation, both of the pericardium and endocardium, the un- 
derlying muscular structure is involved, the subsequent effects being 
degeneration, generally in the form of fatty change, which, by dimin- 
ishing the contractility of the muscular fibre, impedes the action of 
the organ, and gives a tendency to dilatation. 

When pericarditis assumes a chronic form, there is either a thick 
layer of fibrinous lymph, or a considerable quantity of fluid in the 
pericardium, which remains nearly stationary in quantity. 

In the former case the solid lymph undergoes various transforma- 
tions in its progress to organisation ; in which process it is liable to 
fresh attacks of inflammation. When the layer of lymph is thin, 
there will often, for a length of time, be little or no disturbance of 
the action of the heart, provided the valves be sound and the subject 
an adult ; if, on the contrary, the layer of lymph between the two 
surfaces of the pericardium be very thick, the contraction described 
in speaking of the consequences of inflammation ensues ; and this 
sometimes to such an extent as in some measure to cripple or stran- 
gulate the heart. The subsequent progress of the disease may be 
various ; in some cases an adhesion and organisation may be followed 
by the deposition of earthy matter : there is a specimen in the museum 
of Guy's Hospital, where the effused lymph connecting the two sur- 
faces of the pericardium, near the base of the heart, has thus been 
converted into a bony ring ; the patient from whom this preparation 
was taken having suffered from rheumatism, with probably pericar- 
ditis, twenty years previously, and having subsequently enjoyed 
tolerable health until a short time before his death, which was 
brought about by ascites, resulting from disease of the liver, which 
was, to all appearance, primary, rather than the effect of the cardiac 
affection. 

It is also important to bear in mind that after there has once been 
inflammation of the pericardium, followed by adhesion, the patient 
is liable to a recurrence of the inflammation upon any fresh attack of 
rheumatism, though the symptoms will be much masked by the pre- 
existent disease. 

There is scarcely a more difficult diagnosis in the whole range of 
chest diseases than that of adherent pericardium, where Ave have not 
had the advantage of watching the case at the time of the formation 
of the adhesion. When the adhesion is universal, and the lymph not 
very thick, the action of the heart will not be much disturbed ; there 
will be no friction-sound, and unless there be hypertrophy, which is a 
common though not necessary attendant upon such an affection, there 
will be no decrease of resonance. When also the adhesion is near or 



270 CAEDITIS. 

around the base of the heart, the same thing will be the case, though 
here the beat of the apex will be generally high and fixedly so* 
When the adhesion is near the apex the beat will be low, and the 
respiratory movements of the diaphragm and lower ribs diminished ; 
and as in this case there will generally be hypertrophy, we shall 
have the area of the precordial dulness increased, and a rolling or 
tumbling action of the heart. 

When, too, as in the last instances, the adhesion is only partial, we 
may, and generally shall have a friction-sound; and when there is 
adherent pericardium associated, as is often the case, with pleural 
adhesion overlying the heart, depression of the lower part of the 
sternum, with a dimpling inwards of the scrobiculus cordis. 

When the lymph which has glued the surfaces together is near the 
diaphragm, there will generally be considerable dyspnoea, some flat- 
tening of the praecordia, with diminished mobility of the ribs, feeble 
pulse, orthopncea, and symptoms affecting the remote circulation, to 
be hereafter described among the sequelae of cardiac inflammation. 

When a fresh attack of inflammation occurs in a previously adhe- 
rent pericardium, there will be pain, dyspnoea, and palpitation, with 
general febrile symptoms ; but if the adhesion have been universal, 
there will be no friction-sound. If, however, there have been partial 
adhesion, there will often be a soft friction-sound, either single or 
double, according to the situation ; and if there have been old friction- 
sounds, these will sometimes disappear, owing to the adhesion, which 
before had been partial, becoming general. 

In the rare case of a stationary effusion into the pericardium, we 
have the same physical symptoms as in the stage of effusion in acute 
pericarditis, but persistent. 

The treatment of chronic pericarditis should consist of very gentle 
mercurials, as the pil. ipecac, cum scillae, gr. iv. hydrarg. cum cret. 
gr. j. night and morning, with iodide of potass, in doses of about two 
grains three or four times a-day, combined with about ten minims of 
liquor potassae, and half a drachm of nitric aether. Eepeated blisters, 
or an inunction of tartar-emetic ointment, should also be persevered in. 

In regard to the treatment of chronic endocarditis, we would recur 
to what has been stated at p. 261, respecting the importance of dis- 
tinguishing between the effusion of lymph upon the surface of a 
valve, and its deposition between its layers ; and the ground of the 
desirableness of this distinction consists in the greater probability of 
bringing about the absorption of the latter than the former ; and our 
being therefore justified in pushing our remedies, with that object, 
to a greater extent in the one case than in the other. These remedies 
are essentially the same as those just recommended in the case of 
chronic pericarditis, and it is obvious that, to employ mercurials, 
however gently, or even iodine, without a reasonable chance of effect- 
ing our purpose, must, in such a case, be to waste the strength of the 
patient. The diagnosis is indeed a difficult one, and also one in which, 
except in the case of the aortic valves, the physical signs can give us but 

* Walsbe, Diseases of Lungs and Heart. 



HYPERTROPHY. 271 

little assistance ;* but even here the general condition of the patient 
will aid us greatly, since the same state which has been pointed out 
as contraindicating the use of mercury, is precisely that in which it is 
most probable the effusion would be on the free surface of the valve, 
and, therefore, the remedy powerless in promoting absorption. 

The sequelae of inflammation of either surface of the heart are 
highly important, as being in their ultimate effects more destructive 
of life than is the primary disease: the fatal result is, however, in a 
number of instances, brought about by gradual changes, which are 
often more obvious in other organs than the heart: in other cases, 
again, the final and fatal lesion may be in the heart, but not in that 
part of it which had been the seat of the primary disease, the part 
least affected having become the most so, as a remote effect, through 
the intervention of some secondary lesion. 

Before proceeding to the consideration of the secondary and remote 
consequences of cardiac inflammation, or even to that of chronic dis- 
ease of the heart in any form, it is necessary to premise a few remarks 
upon hypertrophy and dilatation of that organ. 

Hypertrophy of the heart may be true or false. 

By true hypertrophy is meant an excessive development of the 
muscular tissue of the organ. The term false hypertrophy, on the 
other hand, is here introduced to express an increase in the volume 
of the heart without a corresponding one in that tissue which consti- 
tutes almost its entire substance in health, and upon the strength of 
which its action depends. This hypertrophy is, therefore, termed 
false, because it arises, not from an excessive nutrition of the original 
structure, but from the deposition of a new one in the substance of 
the organ — a- state of things obviously not incompatible with even a 
deficiency or atrophy of the former. 

Dilatation is an enlargement of one or more of the cavities of the 
heart. When this takes place, without any corresponding increase 
in the absolute quantities of the muscular walls of the cavity, it is 
obvious that there must be a corresponding diminution in their thick- 
ness. Thus, if we suppose, by way of illustration, that owing to some 
cause the cavities of the ventricles of the heart were to be increased 
to twice their longitudinal axes, the proportions to the other dimen- 
sions remaining the same ; the whole area of the surface of each cavity 
would be multiplied by four, and consequently, (if the quantity of 
muscular tissue remained the same,) its thickness at any part must be 
changed in the inverse proportion — that is to say, it must be reduced 
to one quarter. It may be here observed, also, that as the outward 
pressure, or resistance to contraction, increases in the same propor- 
tion as the area of the internal surface — then, supposing the change 
to take place which has just been assumed, we should have, art en's 
paribus, four times the resistance with one-fourth the thickness of 
muscle. In some rare instances it happens that the diminution of 
the thickness of the walls is seen in a still greater proportion, the 
actual quantity of muscular structure being diminished. In the 

* See Dr. Clievers " Ou Diseases of the Heart," in loco oitat 



272 . DILATATION. 

majority of cases, however, with the dilatation there is an increase in 
the absolute quantity of muscle, nearly sufficient to maintain its thick- 
ness at the original standard, though not sufficient fully to compen- 
sate for the increased size of the cavity. This condition is the most 
common of all forms of enlargement of the heart, and is generally 
known as hypertrophy. With dilatation it is also sometimes termed 
excentric hypertrophy, to distinguish it from what has been termed 
concentric hypertrophy, in which there is increase in the thickness of 
the muscular walls without any enlargement of the cavity, or even 
with a diminution of it from the encroachment of the thickened 
muscle ; it is doubtful, however, if this latter ever really exists during 
life, its presence having been probably suggested after death by the 
strong contraction of the hypertrophied muscle. 

The alone cause of true hypertrophy of the heart is an increase to 
the force opposed to the contraction of the muscle or any portion of 
it. This may arise in various ways: thus there may be increased 
difficulty in the passage of the blood through either the systemic or 
pulmonic circulation, the effect of abnormal conditions either of the 
blood, the tissues, or the vessels ; or there may be causes of obstruc- 
tion in the different orifices of the heart, all of which will tend to 
produce dilatation and hypertrophy ; — first, in that cavity which lies 
immediately tergal to it in the course of the circulation, and subse- 
quently in the one lying next behind that, and so on, it may be, to 
all the cavities of the organ. It is conceivable again that a certain 
portion, or certain layers of muscular fibre should have their con- 
tractile powers destroyed or impaired by disease, and if this be so, it 
must happen that, a greater stress being thrown upon the remainder, 
a partial hypertrophy would ensue. Now, we know that other mus- 
cles underlying inflamed membranes lose their contractility, as is 
seen in the bulging of the intercostal spaces in pleuritic effusion, and 
the distension of the intestines arising from loss of contractility of the 
circular muscles in enteritis; and, therefore, it is but reasonable to 
believe, that there may be loss of contractility of the superficial 
fibres, and consequent hypertrophy of those nearer the endocardium, 
as a consequence of pericarditis; and loss of power in the portion'of 
the muscle underlying the endocardium, and consequent hypertrophy 
of those nearer the pericardium, as a consequence of inflammation of 
the former membrane. 

The above are not the only modes in which there may be an in- 
crease in the force opposed to the contraction of the ventricle giving 
rise to some form of hypertrophy or dilatation, although there may 
not be found an obvious mechanical cause for such obstruction. Thus 
the cause may not very uncommonly exist in the blood itself, which 
may be so changed in its physical and chemical or vital properties as 
not to pass freely through the extreme circulation. This state of the 
blood may arise in disease of the depurative organs, and when long 
continued induces hypertrophy and dilatation. The same condition 
of the blood often produces, or, to say the least, is associated with 
thickening and diminished elasticity of the coats of the arteries, 



causes. 273 

extending even to the smaller branches ; and thus it may increase the 
antagonist force to the stystole of the left ventricle. 

It is not improbable that the physical condition of the blood may 
materially influence the facility with which it is transmitted through 
the capillaries ; since it has been ascertained that a fluid which is very 
thin and perfectly liquid, as water, does not pass through capillary 
tubes so easily as one which has been rendered rather viscid by some 
mucilaginous substance : this may be one reason why blood that has been 
deprived of a considerable portion of its albumen, as is the case after 
repeated haemorrhage or serous discharges, appears to circulate with 
more difficulty than healthy blood ; and why such a condition is often 
followed by excentric hypertrophy of the heart. It is true, indeed, 
that with such a state of blood the heart is imperfectly nourished, and 
this may tend to promote dilatation ; but it is a fact, the importance 
of which is perhaps not sufficiently recognised, that repeated losses 
of blood, or long-continued serous discharges, or protracted anaemia, 
are often followed by excentric hypertrophy of the heart. 

Muscular exertion is one of the causes which have been assigned 
for hypertrophy, and there can be no doubt that where strong exer- 
cise is habitually used, the heart, like other muscles, becomes more 
fully nourished ; this is perhaps the nearest approach to true concen- 
tric hypertrophy that is often met with. When unusual or excessive 
exercise is persevered in by one not accustomed to it, or in whom 
the powers of nutrition are feeble, there is obviously a danger of the 
heart becoming dilated rather than hypertrophic, and the most com- 
mon result is excentric hypertrophy ; the proportion between the 
hypertrophy and dilatation varying according to the powers of 
nutrition of the patient. It is true, indeed, that inordinate exercise 
endangers the integrity of the valves (but of that more hereafter), 
but there can be no doubt that when such exertion is used, by one 
whose muscles are but indifferently developed (as from generally 
sedentary habits, for instance), a greater or less amount of dilatation 
may ensue, which may be followed by more or less compensatory 
hypertrophy. For instance, in London, a medical practitioner, 
whose mode of life is not that which is most conducive to the perfect 
nutrition of the muscular tissue, goes through an unusual amount of 
professional exertion ; or a gentleman of the same state of system 
goes, by way of improving, his health, upon a tour on the continent, 
or to the lakes of England or Scotland ; and finding his health and 
spirits invigorated, he walks long distances and ascends mountains ; 
he afterwards finds that he is troubled with a little palpitation, and 
that the action of the heart is at times irregular or intermittent ; this 
is often the effect of dilatation of the left ventricle. The same thing 
may ensue, from great exertion in hunting, rowing, cricket-playing, 
by one who is not in " good-condition," or even in a young lady of 
rather anaemic system, or becoming so towards the close of a season, 
from some more than ordinary fatigue in dancing, or other exciting 
amusement. 

Mental emotion, if violent or long continued, is also reckoned 
amongst the causes of heart disease, and there can be no doubt that 

18 



274 HYPERTROPHY AND DILATATION. 

it may, in states of the system above described, produce dilatation, 
and perhaps hypertrophy. 

The above remarks may appear more applicable to the left than to 
the right side of the heart, but the same principle applies to both : 
and muscular exertion, which drives the blood onward to the right 
side of the heart, has no doubt a tendency to produce excentric 
hypertrophy of its cavities, though the consequence is, in a great 
measure, obviated by the safety-valve action of the tricuspid valve, 
explained by the late Mr. T. "W". King. The chief cause, however, 
of enlargement of this side is obstruction to the pulmonic circula- 
tion, whether arising from disease or defect of the lungs or air- 
passages, or of the left side of the heart. 

The diagnosis of hypertrophy and dilatation will often follow as a 
corollary from that of the 'lesion which has caused it; though at 
other times it may aid in that of the latter. When there is hyper- 
trophy of the left ventricle, the radial pulse will be full and hard, the 
impulse of the heart strong and heaving, and the first sound deep. 
When there is dilatation the pulse will be soft (often sharp, owing to 
the character of the disease which has produced the dilatation), the 
impulse of the heart heaving, but not forcible — both sounds loud and 
sharp. As in both hypertrophy and dilatation there is increased 
precordial dulness, the inference will be in favour of one or the 
other condition, according as the symptoms of either preponderate, 
always remembering that the most common occurrence is the coinci- 
dence of the two. When there is hypertrophy of the right side, the 
precordial dulness extends .more in that direction, the radial pulse is 
almost always feeble, absolutely, — and remarkably so, comparatively 
to the force of impulse of the heart, which is strong and heaving. 
There are also signs of venous congestion, with enlarged liver and 
scanty and high-coloured urine. Hypertrophy of the right heart 
scarcely ever occurs without dilatation ; and the extent of the latter 
is marked by increased feebleness of pulse, engorgement of the liver, 
and diminution of urinary secretion. 

Of the false hypertrophy, the immediate cause is to be found in 
fatty change, with so very few exceptions that we may, for practical 
purposes, regard this change or degeneration, in one or other of its 
forms, as constituting the anatomical condition essential to that 
lesion. In one form of false hypertrophy, there is an increase in the 
volume of the organ (the cavities being enlarged and their parietes 
thickened), but the latter do not consist of firm muscle, but are flabby 
and very lacerable, and are discovered, upon closer examination, to 
be undergoing a process of fatty degeneration. There is a strong 
probability that in many cases this degeneration is a sequela of 
inflammation, though it may no doubt arise under any other condi- 
tion of impaired nutritive energy ; and as this defect may first show 
itself in the heart, the lesion may, in one sense, be regarded as pri- 
mary. Again, it is very probable that some large fatty hearts may 
previously have been the subject of true hypertrophy, but the in- 
creased action necessary to its maintenance has been followed, as its 
necessary consequence, by a lower grade of nutrition (i e. fatty de- 



THEIR CONSEQUENCES. 275 

generation), promoted possibly by a failure of the powers of the 
system at large * It is also very conceivable, on the other hand, 
that fatty degeneration may become the cause of some amount of 
true hypertrophy, owing to the, as yet, healthy layers becoming 
more active, in order to compensate for the diminished power of 
those which have undergone degeneration. 

Another form of false hypertrophy is the deposition of fat upon 
the surface of the heart, described by Dr. R. Quain, in an excellent 
paper upon fatty degeneration of the heart, published in the 33rd 
volume of the Medico-chirurgical Transactions, as fatty growth upon 
the heart. This is generally accompanied by a wasting of the mus- 
cular structure of the organ, and, from the weakness caused thereby, 
with more or less of dilatation. This apparent enlargement of the 
heart is commonly associated with a general tendency to the deposi- 
tion of fat in different parts of the system, as the omentum, appen- 
dices, epiploicae, &c, and a corresponding defect in the powers of 
nutrition as regards the muscular fibre. 

The consequences of true hypertrophy, are generally difficult to 
distinguish from those of the previous lesion, of which it is itself the 
consequence ; the hypertrophy being, in fact, a provision for over- 
coming some obstacle to the performance of a function essential to 
the continuance of life, is, in by far the greater number of cases, 
originally conservative. It may, however, become secondarily 
destructive, from the injury which the contraction of a too powerful 
cavity may inflict upon parts lying between that cavity and the seat 
of the obstruction, which is the cause of the hypertrophy, or even in 
some diverging currents of the circulation ; or the preter naturally 
thick and strong walls of the cavity may oppose too great an obstruc- 
tion to the current from behind, and thus give rise to congestion and 
haemorrhage. For instance, disease in the descending aorta may 
cause hypertrophy of the left ventricle, which, by its preternaturally 
forcible contraction, may injure the ascending aorta or its valves ; 
again, as the force of the systole of the left ventricle is transmitted, 
equally along all the arterial branches, this hypertrophy, which is 
merely compensating as regards the descending aorta and its branches, 
becomes excessive and injurious as regards those arteries which proceed 
from the arch, especially the carotids and the branches, and the con- 
sequence may be disease and even rupture of the vessels of the brain. 

The consequences of dilatation are of an almost opposite character ; 
they are, in fact, those of insufficient force in the central-moving 
power of the circulation. The dilatation and consequent increase of 
the force opposed to the ventricular systole, with diminution of the 
force by which that systole is effected, may go on increasing to such 
a degree that under any (even the slightest) additional exertion or 
obstruction, death may ensue from sudden failure of the circulation. 
For instance, a person labouring under dilatation of the left ventricle 

* Upon referring to Dr. R. Quain's paper upon this subject, I find that this is one of 
the explanations given by that author of the large fatty hearts ; and moreover, that he 
regards it as the most frequent cause of that condition. It may, no doubt, be received 
as such when there has been any apparent cause for previous hypertrophy. 



276 DIAGNOSIS OF TRUE HYPERTROPHY. 

has, not uncommonly, died of syncope induced by the exertion of 
getting out of bed or straining at stool, and where the dilatation is 
mainly of the right ventricle, death from apncea, or obstructed pul- 
monic circulation has been brought on by a slight attack of bronchi- 
tis, or even sudden depression of temperature. The more gradual 
results — obstructed circulation and consequent venous engorgement, 
are, however, the most frequent effects of dilatation ; thus, dilatation 
of the right ventricle gives rise successively to engorgement of the 
liver, ascites, and subsequently, to obstruction through the whole 
venous, and ultimately the arterial system ; whilst a dilated left ven- 
tricle, if the patient is not suddenly cut off by syncope, leads even- 
tually to the same result, by causing obstruction in the lungs, and 
consequently engorgement of the right ventricle and its results. 

The physiological consequences of false hypertrophy or fatty de- 
generation being essentially those of debility of the heart, are nearly 
identical with those of dilatation; there is, therefore, the same lia- 
bility to death by failure of the moving power of the circulation, and 
perhaps a greater tendency to congestion, from the thickened though 
weak cavity not yielding so readily to the distending force from 
behind, and to irregular action, from its not contracting so readily 
when distended by the blood. 

The diagnosis of true hypertrophy, simply as such, consists in a 
heaving and strong impulse of the heart, with palpitation upon mode- 
rate exertion, a full and hard pulse, which is regular and not frequent, 
appearance of congestion of the vessels of the face, giddiness or ver- 
tigo, scanty urine, and in many cases torpidity of bowels, amounting 
almost to constipation. When the hypertrophy, as is most com- 
monly the case, affects mainly the left ventricle, the prgecordial 
dulness extends towards the axilla; the impulse of the heart, besides 
being very forcible, is diffused, the first sound is deeper than natural. 

In dilatation, there is also dyspnoea, and palpitation upon exertion, 
with a tendency to syncope ; the pulse is sharp, and sometimes full, 
but always very compressible ; in some instances, particularly under 
exhaustion, intermittent; the countenance is congested, with more or 
less lividity, in severe cases, and the extremities cold, sometimes 
livid, with a clammy moisure; the urine is apt to be scanty and high 
coloured, and the liver often to be felt below the margin of the ribs. 
There is extended dulness upon percussion, a diffused and rather 
heaving but feeble impulse of the heart ; the sounds, both first and 
second, are loud and sharp, but there is not necessarily any murmur 
with either; though sometimes there is a soft systolic one, the effect 
probably of distension. 

In the more common case of hypertrophy with dilatation or eccen- 
tric hypertrophy, the symptoms will be modified according as the 
greater tendency to one or the other condition prevails. There 
will be dyspnoea with palpitation upon moderate exertion; there will 
be injection of the countenance and prolabia, with more or less 
lividity, according to the extent of the dilatation ; the urine will be 
scanty and high coloured, the more so in more advanced cases ; the 
impulse of the heart will be heaving, and the pulse will not be pro- 



FALSE HYPERTROPHY. 277 

Dortionably full; the latter may be sharp, but then it will be com- 
pressible in proportion to the dilatation. When the dilatation of the 
left ventricle is considerable, there will sometimes be intermission, 
increased by whatever diminishes the volume of the circulating fluid, 
or depresses the nervous powers, as free purgation or diuresis ; the 
tendency to syncope will also depend upon the extent of dilatation ; 
in severe cases there is also orthopnoea ; there will be extended pre- 
cordial dulness, and the impulse of the heart will be diffused and 
heaving, but not forcible, unless there is thickening of the muscular 
walls. The first sound will be lond — dull when there is much thick- 
ening — sharp in proportion as the walls are thin. There is not 
necessarily any abnormal sound, though there is sometimes a soft 
systolic murmur or bruit de soufflet (distension murmur) ; and there 
may be slight murmur, with the second sound, in old cases where 
long- continued distension has caused some degree of attrition, and 
consequent opacity and thickening. 

The diagnosis of false hypertrophy, or enlargement with fatty 
degeneration, will depend much upon the general aspect and condi- 
tion of the patient ; it is more common in advanced life than in early 
manhood; but to this the exceptions are not very rare; and young 
females in whom there is a tendency to obesity are liable to it. In 
early life it is certainly more common in the female than the male; 
it is also observed most frequently in those who are disposed to be 
fat, and in whom there is a degree of sallowness, with a silky and 
sometimes unctuous condition of the surface; the minute veins over 
the whole surface are often injected; it is perhaps more common in 
those who live in large towns and pursue their callings in a confined 
and impure atmosphere than in those who live in the country, and 
are much in the open air. The symptoms are thus described in the 
paper of Dr. E. Quain before alluded to: "A patient complains in the 
earliest stages of being exhausted, particularly by ascending heights ; 
he feels, he says, faint when he gets to the top of the stairs ; though 
not giddy, he feels as if he must fall; and though not breathless or 
panting, sighs and seeks for air." Any unusual excitement, a heated 
or close atmosphere, produce the same effects, at the same time there 
is often experienced an uncomfortable feeling of choking or fulness 
in the chest. In the intervals the individual is pretty well. As the 
disease advances, the attacks become more frequent and severe, and 
often disturb and distress the patient at night ; the temper has been 
observed to be irritable; in .several cases the expression of the 
features appears anxious, and frequently the countenance is sallow ; 
oedema of the legs and copious perspirations from very slight causes 
appear amongst the associates of the disease ; the pulse is generally 
affected, but the mode in which it is so depends, no doubt, on the 
part of the heart affected, and on the extent and degree of the dis- 
ease. Irregularity is one of the most frequent alterations, weakness 
is another, slowness a third. "In general, weakness, irregularity, 
and slowness of the pulse are the characters which we most frequently 
find." As the disease advances the symptoms become more marked, 
the various effects of languid and feeble circulation show themselves, 



278 HYPERTROPHY AND DILATATION. 

angina pectoris is perhaps fully developed, or the patient is cut off 
suddenly by some of the effects connected either immediately or 
remotely with the lesion itself. 

The physical signs are, extended precordial dulness when (as is 
generally the case) the heart is enlarged, a very feeble, though some- 
times diffused impulse of the heart; the first sound very feeble, it is 
doubtful if any murmur is necessarily present; when a systolic mur- 
mur is heard it is probably the effect of distension. In two out of 
eighty-three cases in Dr. Quain's paper, the second sound was feeble 
or imperfect ; this was ascribed by him to fulness and dilatation of 
the ventricle preventing perfect closure of the semilunar valves. 

As regards the treatment of simple or primary hypertrophy, it 
is, as has been shown, so rare a disease that it will seldom, if ever, 
be necessary to direct our remedies especially to it. The cases 
which approach most nearly to this form of hypertrophy, are those 
in which there is a tendency to an excessive development of the 
muscular system, increased, it may be, by great muscular exercise ; 
the danger being that either the valves or the arteries will be 
injured by the too forcible contractions of the ventricle. The 
obvious indications in this case are the avoidance of the causes 
which may have led to the hypertrophy, and the use of a moderate 
unstimulating diet. Dieuretics, with alkalies or alkaline carbonates, 
may be occasionally employed, and all tendency to congestion coun- 
teracted by maintaining a steady and rather free action of the bowels. 
It is only, however, in extreme cases, as when, for instance, there is 
reason to apprehend hyperemia of the brain, that bleeding is to be 
resorted to ; since whatever impairs the nutrition of the body may 
favour fatty degeneration, which is probably one of the remote con- 
sequences of hypertrophy. 

The treatment of the false hypertrophy, or fatty change of the 
heart, can be little more than prophylactic, since as Dr. K. Quain very 
justly observes, ""We have no evidence to show that we can restore 
muscular fibres which have been destroyed; all, therefore, that we 
can hope for, and that not always, is to arrrest or suspend for a time, 
the progress of the disease by improving the quality of the blood, 
and thus supporting the vigour of those portions of the heart still 
uninjured." Nevertheless there is good reason for believing that, in 
cases not very far advanced, much may be effected by measures of 
this description; and by so regulating the circulation as to prevent 
all unusual distension of any of the cavities of the heart. When a 
tendency to this disease exists in young subjects, a mode of treat- 
ment, such as would be applicable in cases of obesity, must be pur- 
sued; accordingly, a spare diet of lean meat, and a moderate allow- 
ance of bread or biscuit, but little vegetables, and no fermented 
liquors ; active exercise being at the same time perseveringly followed, 
much after the plan recommended by Dr. T. K. Chambers; liquor 
potassae may be taken in milk, in doses from half a drachm to a 
drachm : and, above all things, a pure bracing atmosphere should be 
sought. In this manner great relief has been obtained in several 
instances which have occurred to the author. 



TREATMENT. 279 

The greatest danger from this disease, however, arises in more 
advanced life, when active exercise cannot be borne, owing to the 
general weakness, and when any considerable exertion, by hurrying 
the blood to the heart, might involve the danger of over-distension 
of that organ; but even under these circumstances, we may gain 
much from a system of diet similar to that which has been recom- 
mended above; and we may hope for equal benefit from a pure 
atmosphere, since this form of degeneration is much accelerated, if 
not induced, by the want of that essential depurating agent, without 
a sufficient supply of which, the consumption of the redundant car- 
bon in the extreme circulation, and the excretion of the carbonaceous 
compounds by the lungs, cannot proceed. The liver, it is true, may 
often, under these circumstances, be stimulated to supply, to a limited 
extent, the defect of the action of the lungs, and so may also the skin : 
these ends may be promoted by the frequent use of aperients, which 
must not be of a depressing character ; for instance, the compound 
decoction of aloes with the addition of a few grains of rhubarb and 
acetate or tartrate of potass (F. 42) :* should this draught not prove 
sufficiently active, its use may be preceded by some colocynth pills 
with calomel. The liquor potassae and extract of taraxacum may 
also be administered in these cases alternately with saline diapho- 
retics. These measures, however, can be regarded only as palliative, 
and as from the debility of the heart there is a tendency to engorge- 
ment of the liver, the difficulty of maintaining a free action of that 
organ will generally increase. Some relief may also be given to the 
pulmonic circulation, and through it to the right side of the heart 
and the liver, by expectorants, which should generally be rather of 
a stimulating character, such as the combination of squills and 
ammonia. 

The great object, however, being, if possible, to arrest the tendency 
to fatty change, the chief reliance must still be placed (in conjunction 
with a rigid adherence to the prescribed regimen) upon such exercise 
as can be taken (without inducing palpitation or faintness) in the 
open air, in the country, or by the sea-side. Where the patient is 
able to ride, gentle horse-exercise will be most desirable ; otherwise 
he should drive in an open carriage, or walk moderately. 

Before proceeding to consider the treatment of the more common 
cases of hypertrophy with dilatation, it will be well to trace the 
effects of its most frequent cause, namely, lesion of the orifices, pro- 
ducing either regurgitation, or obstructions, or both; as we then shall 

* (42) R. Pulv. Rhei, gr. xii. 
Pot. tart. ^ ij. 
Decoct. Aloes co. ^ ss. 
Sp. Amnion, arom. ttl xx. 
Aq. Pimentse, »g vj. Misce. 
Ft. Haust. ; to be taken in the early part of the morning. Or, 

R. Sodaa bicarb. 

Pulv. Rhei, aa gr. xii. 

Decoct. Aloes co. ^ ss. 

Aq. Pimentse, 3 vj. Misce. 
Ft. Haust. 



280 HTPERTKOPHY AND DILATATION. 

be in a position to take a more rational view of the management of 
chronic disease of the heart in general. Now, as has been remarked, 
the essential cause of hypertrophy of any portion of the muscular 
tissue of the heart, is an increased stress thrown upon those fibres ; 
and as among the most frequent causes of such increase is obstruction 
in the orifices, or defect in the valves, we will commence with the 
ventriculo-aortic orifice. 

When there is thickening of the valves and contraction of the 
orifice of the aorta, it is obvious that there must be an increase in 
the resistance to the exit of the blood, and consequently that hyper- 
trophy of the left ventricle with dilatation may be expected to ensue ; 
and such is almost always the case ; but it may not be at first so 
obvious that the same result will follow regurgitation through these 
valves with little or no obstruction. Supposing that the orifice is 
clear, but that the valves remain open, there will be a full jet into the 
aorta, but as soon as the systole is complete, a portion of the blood 
will return into the ventricle, which is in the mean time receiving 
fresh blood from the auricle, and thus becomes over-distended, and 
called upon for an increased amount of contractile effort. Having, 
in fact, besides maintaining the systemic circulation, to keep up a to- 
and-fro motion of a certain quantity of blood, which is continually 
passing backwards and forwards through the valves (without, as it 
were, the pale of the circulation), the left ventricle must either become 
hypertrophic, to sustain this additional effort, or must yield under it, 
and become dilated. 

When the impediment to the circulation is not very great, and the 
hypertrophy is nearly sufficient to compensate for the increased dif- 
ficulty, the patient may live for months and years, under favourable 
circumstances, with comparatively but little inconvenience; when, 
however, the dilatation continues to increase in a greater proportion 
than the hypertrophy; or, which is the same thing, when there is 
not hypertrophy sufficient to prevent the dilatation, it happens either 
— that the patient dies suddenly from syncope, or — that owing to the 
inability of the left ventricle to empty itself, there is an obstruction 
to the entrance of blood into it from the auricle, and the effect is 
engorgement of the lungs and the right side of the heart, engorge- 
ment of the liver, ascites, anasarca, and death from apncea, in the 
manner to be presently described as occurring in disease of the 
mitral valve. 

The symptoms of lesion of these valves have been already pointed 
out ; but it may be here remarked, that as long as there is no other 
disease obstructing the circulation, the pulse, though splashing, or 
having the other characteristic conditions, continues regular ; but if 
any cause arise to obstruct the pulmonic circulation, as, for instance, 
an attack of bronchitis, then it will become irregular, for the reason 
that the cavity of the ventricle being enlarged by dilatation, the 
diminished supply of blood will not be sufficient to stimulate it to 
regular contraction. 

When there is chronic change in the left auriculo- ventricular 
orifice, the effect upon the circulation will differ little, whether that 



DISEASED MITRAL VALVE. 281 

change takes place in the way of thickening of the valves and con- 
traction of the orifice, or of imperfect closure, arising either — from 
puckering of the valves, — from vegetations upon their edges, — from 
rupture of the chordae tendinas, — from dilatation of the ventricle 
drawing away the origins of the columnse carneae, or — from dilatation 
of the orifice itself. The immediate effects, however, upon the heart 
will be somewhat different ; if, for instance, there be contraction of 
the orifice, the current of blood into the ventricle being small, it will 
be but feebly excited to contract, and owing to this comparative 
inactivity, the cavity will be small, and the walls rather thin ; and 
since the current into the ventricle is small, that which flows from it 
must be so likewise ; and, if there be no other counteracting disease, 
the aorta will be small also ; since, as has been already explained (p. 
37), the size of an artery is regulated by that of the current of blood 
passing through it. This state of things does not, perhaps, always 
continue, as owing to the obstruction being propagated backwards 
through the pulmonic and venous systems, it at length reaches the 
left ventricle, which then begins to dilate, and becomes more or less 
hypertrophic. 

When there is regurgitation through, the mitral valve, the orifice 
being not contracted, or, as is not uncommonly the case, being dilated, 
there will not be the same want of stimulus to the left ventricle, which 
will then be not diminished, or what is more likely even increased 
in capacity and thickness. 

The effect upon the pulse will, in either case, be nearly the same, 
as it will be frequent, very small, and often intermitting; as a general 
rule, if there be intermission, the lesion of the mitral valve is, pro- 
bably, contraction rather than regurgitation. 

The most serious consequences of this lesion, however, take place 
in the direction opposite to the course of the circulation. The first 
result is dilatation of the left auricle, which sometimes becomes so 
much enlarged as to press upon and flatten the left bronchus ; not, 
indeed, so as materially to embarrass the respiration, but sometimes 
sufficiently to cause a bronchial respiration to be heard in that situa- 
tion. Whether this sound can be made available for diagnosis is, at 
present, questionable. From the left auricle, the obstruction extends 
to the pulmonic veins and arteries, causing great delay in the circu- 
lation through the lungs, and thereby preventing the aeration of the 
blood, and giving rise to general venous congestion, with lividity of 
the lips, cheeks, and extremities. The bronchial membrane also 
becomes much congested, and the capillary circulation is sometimes 
relieved by the effusion of serum into the cells and bronchial tubes ; 
this, sometimes, occurs to such an extent as to become dangerous by 
threatening death from apncea. 

From the lungs, the obstruction extends to the right ventricle and 
auricle, producing, in the first instance, over-distension of the former; 
this, however, brings the safety-valve action of the tricuspid valve 
into play, thereby allowing much of the blood to be thrown back 
into the former, and delaying and diminishing the engorgement of 
the lungs that would otherwise speedily ensue. It has been sug- 



282 HYPERTROPHY AND DILATATION. 

gested by Dr. Chevers, in one of a most interesting series of papers 
originally published in the London Medical Gazette, that the venous 
circulation may also sometimes be relieved by the bronchial artery 
taking on the functions of a vein, though this can hardly be expected 
to happen except in young subjects. The immediate consequence 
of this is engorgement of the right auricle and accumulation of blood 
in those great reservoirs the liver and spleen. In the former, hepatic 
venous congestion takes place, and the organ becomes rapidly en- 
larged. This is followed by portal congestion, and engorgement of 
the veins converging to form the vena porta, and hyperemia of 1jie 
gastro-intestinal mucous membrane, which often give rise to much 
irritability of the stomach, and sometimes to diarrhoea; from the 
same cause ascites is also produced, whilst the congestion of the 
systemic veins produces general anasarca. The disease is terminated 
sooner or later by apnoea, either from the direct effect upon the lungs, 
or from that cause aided by the pressure upon the diaphragm, arising 
from the enlargement of the liver, and the accumulation of fluid in 
the abdomen. 

Such is the least speedy termination of this most serious lesion of 
the heart, though it may prove fatal at any period, either in the 
manner above pointed out — by a very extensive pulmonary apoplexy, 
— by a combination of apnoea and syncope, arising from inability of 
the right ventricle to propel the accumulated blood by which it is 
distended, — or, it may be, by coma, the effect of venous congestion 
in the brain. 

As regards the diagnosis of lesion of the valves of the left side of 
the heart, there is no great difficulty, in the earlier stages especially, 
in distinguishing between disease of the aortic, and that of the mitral 
valve, though there is often much, in distinguishing the latter from 
other affections of the pulmonic circulation. Before the obstruction 
produced by disease of the aortic valves has extended far back along 
the course of the circulation, there will be little general distress, and 
the patient may be scarcely aware that he is labouring under any 
disorder of importance. It is then only to be recognised by the 
characteristic murmur traceable along the course of the ascending 
aorta, and by the almost equally characteristic pulse (p. 69-70). In the 
more advanced stages, when the effects upon the circulation more 
closely resemble those arising from disease of the mitral valve ; the 
same means of diagnosis will distinguish between this and any other 
cardiac lesion, except, perhaps, disease of the ascending aorta itself. 

When there is disease of the mitral valve, whether obstructive or 
regurgitant, the earliest symptoms will be those of obstruction to the 
circulation through the lungs, which may sometimes be sufficient to 
give rise to haemoptysis ; this, with the very small, or intermittent 
pulse, will be sufficient to direct attention to the investigation of the 
condition of the organs concerned in the pulmonic circulation ; and, 
if to these symptoms there be added those of venous obstruction 
already described, there can be little doubt of the existence of disease 
in some portion of this circuit; and if there be besides a bellows' 
murmur with the first sound, increasing in distinctness towards the 



DISEASED VALVES — PKOGNOSIS. 283 

axilla, the probability of disease of the mitral valve will be farther 
increased ; and this murmur will generally indicate regurgitation. 

Narrowing of the orifice of the mitral valve is also generally at- 
tended with a systolic murmur, though this murmur is rather more 
to the right than in the case of regurgitation, that is to say, a little to 
the left of the origin of the aorta; this latter murmur may be dis- 
tinguished from that of disease of the valves of the aorta, by its not 
following the course of that vessel. The presence or absence of these 
murmurs is not, however, to be regarded as deciding the question of 
the presence or absence of disease of the mitral valve, since their 
immediate connection with such disease is, to say the least, doubtful. 

The prognosis of valvular disease of the heart may be inferred 
from what has been said of its ordinary progress — it is, in the main, 
unfavourable; at the same time, it must have been apparent, that 
there is a great difference between the rapidity with which a fatal 
termination may ensue in one form of disease or in another. Thus 
the prognosis is much less unfavourable in disease of the aortic valves 
than in that of the mitral. 

When there is evidence solely of disease of the aortic valves, as 
obtained by the state of the pulse, and the stethoscopic signs, we may 
reasonably hope that, under careful management, life may be pro- 
longed in comfort for many years ; and, in the case of young persons, 
we may even go further, and, judging from experience, assert that it 
is at least possible that the injury may be so far repaired, or the state 
of the orifice may be so adapted to the condition of the valves, that a 
considerable degree of vigour and activity may be maintained, and 
the patient grow up to perform the duties of any but a very laborious 
station in life. 

Disease of the mitral valve, on the other hand, leads to death, as it 
were, by a shorter route ; though, even here, much may be done to 
delay its termination, when the narrowing or regurgitation, and con- 
sequent pulmonic obstruction, are not very great. In women, too, 
the establishment and maintenance of the catamenial discharge may 
afford great relief, though a fatal termination may be expected when 
this function ceases. 

It has been pointed out, however, that there is much obscurity 
about the state of the mitral valve, when the sigmoids also are dis- 
eased ; and therefore we must be guided rather by the effects upon the 
circulation generally, particularly upon that through the right heart, 
than by any stethoscopic signs of the local affection. As a general 
rule, therefore, when we have the signs merely of disease, whether 
obstructive or regurgitant, of the aortic valves, and no evidence of 
obstructed circulation elsewhere, without dyspnoea, venous conges- 
tion, or scanty urine, our prognosis, though not favourable as regards 
the ultimate result, may be such as to give a hope of years of comfort 
and usefulness. But where there are signs of obstructed pulmonic 
circulation, engorgement of the liver, or the urine is scanty, we must 
apprehend, either — that the obstruction caused by the disease at the 

orifice of the aorta is extending itself to the left auricle and the hings 

• i t • 
— or that mitral disease exists, though masked by that of the aorta ; 



284 TREATMENT. 

and in this case the prognosis is bad. Disease of the mitral, again, 
is essentially unfavourable, but even here we must judge rather by 
its results than by the topical proofs of its existence, and when the 
pulmonic circulation* remains tolerably free, and there are but little 
or no dyspnoea, lividity, or oedema, and the urine is not very 
scanty, we must not entirely destroy the hopes of the patient and 
his friends. 

The general principles of the treatment of the sequelae of inflam- 
mation of the heart, whether of the pericardium, the muscular tissue, 
or the endocardium, follow pretty directly from the explanation 
which has been given of their origin, and tendency to a fatal result. 
The first indication in the treatment of such disease is to prevent, if 
possible, any farther injury being inflicted upon the weakened struc- 
ture by the forcible action of the ventricle, the next to counteract 
that tendency to excessive dilatation which is one of the steps lead- 
ing to a fatal issue, and, thirdly, where this dilatation has become 
such as to impair materially the moving power, to obviate the effects 
of such weakness, whether manifesting itself in the form of a tend- 
ency to syncope, or of venous congestion. 

In applying these principles to the aortic orifice and its valves, we 
may remark that the most frequent cause of disease of this orifice is 
endocarditis, and of that endocarditis the most frequent cause is 
rheumatism, and next to it, uraemia, as in albuminuria, besides which 
various morbid poisons, as those of scarlatina, influenza, &c, may 
produce the same effect ; but besides that, excessive muscular exer- 
tion may give rise to a local endocarditis, which causes thickening 
or adhesion of the valves, or, when very great, to direct injury in 
the way of laceration or retroversion; and exertion of the arms, 
especially when raised above the head, as is seen in sawyers and 
sailors, rowing, when violent or long sustained, is apt to produce the 
same injury. It is to be remembered, however, that such efforts are 
more especially dangerous to those who are not in the habit of 
making them. Thus a gentleman runs a much greater risk by a 
rowing match than does a waterman. Mental emotion is another 
cause, and to these may be added excesses of all kinds, as at once 
exciting and debilitating. 

"Whenever, then, we have reason to suspect that there has been at 
any time endocarditis (and the very fact of a previous attack of rheu- 
matism should arouse such a suspicion), we should lay down the 
strictest injunctions for the avoidance of. all these exciting causes, 
and the necessity for such restrictions becomes tenfold when we have 
the slightest auscultatory sign of any lesion of the valves. It may 
be said, indeed, that in regard to mental emotion, but little can be 
done, yet where we have to do with young subjects, and such cases 
are not uncommon, we may explain to parents the possibility of 
strengthening or acquiring habits of self-possession, which will do 
much to counteract the effects of circumstances in exciting mental 
emotion ; and in all we can enjoin the necessity for avoiding scenes 
and places where they are likely to be exposed to such excitement. 

In arresting further injury to these valves, much is to be done by 



DISEASED AORTIC VALVES. 285 

dietetics. The diet should be carefully regulated as to quantity and 
quality, of both solids and liquids. As regards food, it should be 
nutritious, unstimulating, and not great in point of bulk. Thus a 
moderate meal of meat should be allowed once a-day, and with about 
half-a-pint of liquid ; this may be either light malt liquor, as bitter 
beer or ale, or water, with a glass or two of wine, according to the 
habit and general condition of the patient. For breakfast, cocoa 
where it agrees, will be a good beverage, or otherwise, "cafe' au lait;" 
both these are to be preferred to tea, but of none should more than 
half-a-pint be taken ; an early dinner, about four hours after break- 
fast, is generally to be preferred, and about four hours after that, a 
little tea (not more than two tea-cups), and at night a very light sup- 
per, as a small basin of arrow-root, sago, or tapioca, or a sandwich, 
with a little wine and water, where there is any tendency to exhaus- 
tion ; but except during sleep, nourishment should be taken at inter- 
vals of about four hours. Exercise must be regulated upon the 
the same principles ; walking, but not against any steep ascent, and 
gentle riding, as being conducive to healthy nutrition, serve to obvi- 
ate the tendency to dilatation ; always provided that they are neither 
attended or followed by uncomfortable palpitation. A pure and 
moderately -bracing air is also desirable, and upon much the same 
grounds. Cold bathing is inadmissible, but where the affection is 
but slight, tepid sponging may be used with safety. 

The great object being to keep the circulation as uniform and 
tranquil as possible, an equable temperature must be carefully main- 
tained; for this purpose, the clothing should be uniformly warm 
over the body, and while heat is to be shunned as stimulating to the 
heart, sudden exposure to chills must be as carefully avoided, lest 
by driving the blood from the surface, it should call for too great an 
effort to return it, or failing this, endanger the life of the patient by 
syncope. 

In the period of the disease of which we are now speaking, that, 
namely, in which there is opportunity for preventive management, 
there is not occasion for much therapeutic treatment ; but the occa- 
sional employment of remedies tending to regulate the amount of 
the circulating fluid and allay palpitation, will promote the comfort 
and prolong the life of the patient. Eepeated small bleedings have 
been proposed with this view, but their employment is most mis- 
chievous. Blood should not be drawn except to relieve some alarm- 
ing congestion in the brain or lungs, and then its abstraction can 
only be regarded as an unavoidable evil. Where any tendency to 
congestion, manifesting itself in vertigo, congestion of the counte- 
nance, or even increased excitement of the heart, seems to indicate 
the expediency of some reduction in the volume of the blood; the 
best means of effecting it will be by moderate hydrogogues and 
diuretics. For this purpose, two scruples of the pulv. jal. co. may be 
administered. The following formula will perhaps be a convenient 
one.* (F. 43.) 

4 * (43) R. Pulv. Jalapoe co ►) i v « 

Syvupi Zingibcris, ^ ss. Misce. 
One-half to be taken early in the morning. 



286 TREATMENT. 

In promoting the action of the kidneys, and at the same time re- 
lieving the palpitation, a combination of senega with some diuretic 
will be eminently serviceable. The modus operandi of the senega 
under such circumstances is not quite obvious, but it certainly is 
specially useful in palpitation arising from aortic disease, though it 
has not the same good effect in disease of the mitral valve. The 
accompanying formula may be useful* (F. 44.) 

When there are any symptoms indicating the supervention of 
inflammatory action, as increased sharpness of pulse, with furred 
tongue, and other signs of pyrexia, without any other assignable 
cause for such excitement, we must, of course, apply the ordinary 
means of subduing such inflammation ; but this must be done with 
every consideration for the strength of the patient. If necessary, a 
small quantity of blood may be taken, or, what is better, the patient 
may be cupped over the region of the heart to from four to six 
ounces, and if the skin is not hot a blister may be applied, and 
calomel, antimony, and opium, with salines, may be given. As re- 
gards the mercury, however, salivation is to be avoided, since it 
promotes spanasmia, which favours dilatation. 

It is to be remembered that in treating of the early period of dis- 
ease of the aortic orifice, we are speaking of the most hopeful form 
of heart disease, and that in which most may be done by judicious 
management, but in which, on the other hand, irremediable mis- 
chief may be inflicted by a single false step. A needless abstraction 
of blood, though it may even seem for the time to afford relief, or 
the wanton use of any lowering remedies, or even too much absti- 
nence from nutritious diet, may lead to dilatation without hyper- 
trophy, and its disastrous consequences ; whereas over-stimulation or 
over-exertion may aggravate the primary mischief. For the latter 
reason iron will not generally be admissible as a tonic, but zinc in 
the form of sulphate, or where there is irritability of stomach, of 
oxide, will be useful (F. 45) ;f where there is much palpitation it 
may be combined with camphor (F. 46)4 

In the next period we have to do with increased dilatation and 
consequent delay in the passage of blood through the left heart, 
manifesting itself by symptoms of obstruction to the circulation 

*(44) R. Sp. JEth. nit. 3 ij. 

Tinct. Hyoscy. g iss. 
Decoct. Senegee, § iij. 
Mist. CamphoriB, quant, suf. 
To make a § iv. mixture, of which the one-fourth part is to be taken 
three times a-day. 

f (45) R. Zinci Sulphat. (vel Oxidi), gr. iij. 
Ext. Lupuli, gr. vj. Misce. 
Ft. Pil. vj. ; to be taken three times a-day ; increase gradually the dose 
of the zinc, gr. iij. 

% (46) R. Zinci Sulphat. (vel Oxidi), gr. i — iii. 
Camphorse purse, gr. i. 

Ext. Hyos. gr. ii. Misce. . 

Ft. Pil. ; to be taken three times a-day. 



DISEASE OF THE MITRAL VALVE. 287 

through, the lungs and liver, as dyspnoea, sometimes slight icteric 
tinge, scanty and turbid urine, &c. 

There is now less to be done in the way of prevention, but rest 
must be most rigidly enforced. The bowels must be kept freely 
opened by moderately warm aperients and occasional doses of colo- 
cynth and calomel, or blue pill ; or, where there is much cedema, 
the compound jalap powder may be employed. Diuretics will also 
be of service, and amongst these the combination of senega and 
nitric ether, recommended above. There is now more tendency to 
palpitation, and the camphor, henbane, and zinc may be used, though 
where the palpitation is very troublesome the zinc should be omitted. 
In the still more advanced cases, when palpitation and dyspnoea 
with orthopncea become urgent, and signs of venous congestion begin 
to show themselves, the disease is evidently drawing to its termina- 
tion, and the treatment must be mostly palliative, or similar to that 
employed in disease of the mitral valve. 

The treatment of disease of the left auriculo-ventricular orifice is, 
for the reasons already adduced, less promising than that of the aortic, 
and we have to deal almost from the first with obstructed pulmonic 
circulation and venous engorgement, with their consequent evils. 
The chief indications here will be to relieve the pulmonic circulation 
by expectorants, which must not, however, be of a very stimulating 
character, and the portal and general circulation by purgatives and 
diuretics ; though from the latter we often obtain but little effect, 
owing to the engorgement of the liver. When there is no albumi- 
nuria, the combination of squills and blue pill or grey oxide (F. 47),* 
may be continued till the gums are slightly affected, or till there is an 
obvious improvement in the secretion of urine. A diuretic mixture 
may be administered in the course of the day, and a moderate but 
effective purgative alternate mornings (for this purpose F. 13, without 
the colchicum, will be applicable). The combination of senega with 
nitric aether, recommended above, may also be administered, but we 
cannot expect the same benefit from it as in disease of the aortic 
valves. The addition of tincture, or oxymel, or vinegar of squills 
will render it more expectorant, and therefore more applicable to 
this form of disease, which, both in its symptoms, its consequences, 
and the treatment required, closely resembles pulmonic congestion, 
caused by long-continued chronic bronchitis. Upon these grounds 
great temporary relief may often be obtained by large blisters 
applied upon the sternum or between the shoulders: and as our 
object should be to induce free -serous discharge rather than irrita- 
tion, the blister should be removed at the end of eight hours, and a 
large linseed poultice applied in its place. 

* (47) R. Pil. Hydrarg. gr. iij, 
Pil. ScillEe co. gr. vij. 
Ft. Pil. ij. ; to be taken at bed time. Or, 

R. Hydrarg. Oxidi, gr. iss. 

Pil. Scillre co. gr. x. 
Ft. Pil. iij ; to be taken at bed time. 



288 ACUTE AOKTITIS. 

The remarks which, have been made upon the treatment of the 
effects of disease of these two sets of calves apply, with but little 
alteration, to the direct and palliative treatment of hypertrophy and 
dilatation arising from other causes. Where the enlargement is 
merely of the left ventricle, the effects upon the circulation will be 
much the same as those arising from the second stage of disease of 
the aortic valves ; and the treatment, as regards regulating the volume 
of the blood and the activity of the excretory organs, must also be 
the same; in like manner, where the enlargement is mainly on the 
right side, the treatment will be the same as that most applicable 
to disease of the mitral valve. As regards our efforts at producing 
some permanent relief, we must be guided by what insight we can 
gain into the probable cause of the enlargement. When, for instance, 
hypertrophy of the left heart is the effect of thickening of the sys- 
temic arteries, we must regard the left ventricle as suffering over- 
distension, arising from an increase in the force which opposes its 
systole, and endeavour to regulate the circulation much as in early 
disease of the sigmoid valves. 

Where, again, we have to do with cases in which there has been 
dilatation of the left ventricle, from over-exertion under unfavourable 
circumstances (as pointed out p. 273), tranquillity, moderately good 
living, and regular exercise will go far to obviate the mischief. 
Where the dilatation is the effect of weakness induced by carditis 
(p. 280), gentle alterative remedies, as iodide of potassium, or, per- 
haps, iodide of zinc, which will combine the advantage of an alterative 
and tonic, should be used, and we must pursue, in other respects, the 
same plan as in the last case, but with greater restriction as to exer- 
cise and less hope of radical amendment. 

Acute inflammation of the aorta, or acute aortitis, is a very rare 
disease, and one of which the signs are very obscure. Dr. Chevers, 
to whom we are indebted for most of our knowledge respecting it, 
states that it proves fatal by sesthenia, complicated with comatose 
symptoms. The pulse is exceedingly rapid, often indistinct, though 
somewhat wiry; there being at the same time much obstructed 
pulmonic circulation, stertorous breathing, venous congestion, and 
swollen extremities. For the anatomical changes produced by acute 
inflammation of the arteries, we would refer the reader to the work of 
Doctors Jones and Sieveking. 

The diagnosis of acute aortitis is very obscure; the difficulty is, no 
doubt, in great measure, owing to the rarit}^ of the affection, particu- 
larly as a primary lesion ; and where it has supervened upon other 
diseases, it has, as Dr. Walshe observes, produced no additional symp- 
toms besides increased irritability or distress. Where however we 
have, in addition to the latter symptoms, pain, thrilling pulsation, 
and arterial murmur along the course of the aorta, we may suspect 
this disease, though we can hardly venture further than a surmise in 
our diagnosis. 

Chronic inflammation of the aorta and large arteries is a much 
more common occurrence, producing fibrinous deposit, atheroma, ossi- 
fication, aneurism, and, sometimes, ulceration. For a description of 



CHRONIC AORTITIS. 289 

these changes, we would again refer to the work of Drs. Jones and 
Sieveking. The importance of these affections in regard to the prac- 
tice of medicine, consists in their destroying the elasticity of the 
artery, rendering it in some parts nnable to recover its proper size 
nnder distension, and in others, preventing its yielding sufficiently to 
the injecting force of the heart. Hence there will arise an irregu- 
larity in the calibre of the artery. It becomes in some parts dilated, 
and in others narrowed. One result of this loss of their proper 
contractility on the part of the aorta and large arteries is, that the 
machinery whereby the uniform current of blood is maintained 
being impaired, the pulse becomes splashing, or of the water-hammer 
character, much resembling that produced by disease of the aortic 
valves (p. 70). The effect of this condition of the aorta upon the 
heart must likewise be nearly the same as that resulting from disease 
of the above-named valves, and there will ill course of time ensue 
hypertrophy and dilatation, with their consequences, the tendency to 
fatal termination being the same. 

The physical signs of this form of the disease of the thoracic aorta 
also closely resemble that of disease of the valves: there will be a 
systolic murmur traceable up the course of the ascending aorta, and 
the same will be heard along the spine ; the pulsation of the aorta will 
also be frequently felt above the sternum ; and as the disease generally 
more or less implicates the arteries, we shall have similar murmurs in 
the course of the innominata, the sub-clavian, or the carotids. 

These murmurs must of course be carefully distinguished from 
anasmic ones; but besides this history of the case, and in most in- 
stances the absence of anaemia sufficient to produce the murmur, 
there will be the characteristic pulse, with the hard artery (p. 70). 
Disease of the arch of the aorta is often accompanied by great dysp- 
noea, liable to serve paroxysmal aggravations, arising probably from 
irritation of the recurrent nerves. 

Where we have strong reason for believing in the existence of 
acute inflammation of the aorta, our treatment should be decidedly 
antiphlogistic ; not indeed that general bleeding will be tolerated in 
the majority of instances, since the moving powers of the circulation 
are sometimes so much depressed as to threaten to destroy life by 
apnoea ; cupping at the sternum or in the course of the spine will, 
however, generally be borne. Where the depression is very great, 
we must be content to employ dry cupping ; and where there is no 
great heat of skin, a blister may be applied along the side of the 
spine ; calomel, opium, and antimony should also be employed, and 
saline diaphoretics administered in the intervals. 

The effects of chronic aortitis, are those of alteration in the calibre 
of the aorta, or of loss of its contractility, are, for reasons already 
explained, the same as those of obstruction to the circulation from 
coarctation or thickening of the aortic orifice, and must be treated 
accordingly. 

Aneurism is a most important form of disease of the aorta. Into 
the varieties and anatomical conditions of aortic aneurism we do not 
now enter, our business being mainly with its symptoms and manage- 

19 



290 ANEUKISM, 

ment. Chrome changes in the aorta of the character above alluded 
to are more frequent in its ascending portion and the arch, than at a 
greater distance from the heart, and it is probably upon this account 
that aneurism also is more frequent in the same situation, not to men- 
tion that this part of the artery is more than any other exposed to the 
direct impetus of the blood thrown from the left ventricle. 

Sometimes these aneurismal pouches form so near the origin that 
they have been known to burst into the pericardium, causing instant 
death to the patient; though the lesion has manifested itself by no 
appreciable symptoms during life. 

When the aneurism forms higher up in the ascending aorta or in 
the arch, it generally increases so as to form a considerable tumour, 
and then its presence becomes apparent, by the signs of the pressure 
upon the neighbouring structures, by the effects upon the circula- 
tion generally, and by physicial changes presented in the» aneurism 
itself. 

The effects upon the neighbouring parts may not manifest them- 
selves for some time. When the tumour is in the ascending aorta 
these symptoms are for a long time very obscure ; but if the patient's 
life be not early destroyed by the giving way of the sac, a pul- 
sating tumour shows itself in the course of the vessel. Sometimes 
again the nature of the effection becomes apparent from a sudden 
gush of arterial blood from the. mouth. 

We noticed, when speaking of phthisis, that the arteries are the 
structures which, of all others, are the slowest to become involved in 
the destruction of the surrounding lung, and, it would appear, that 
even when they do get morbidly enlarged, the neighbouring tissues 
become absorbed, rather than the artery itself, under the pressure ; so 
that the sternum or cartilages of the ribs, or the trachea, or bronchi, 
disappear before it ; or, if it be seated more posteriorly, the oesophagus 
or bodies of the vertebra? are similarly destroyed. When the aneurism 
is in the arch of the aorta, one of the earliest signs is not unfrequently 
a peculiar huskiness of voice, with difficult resjDiration, attended with 
some distress, the effect probably of pressure upon the recurrent 
nerve: vague lancinating pains in the chest and back, sometimes 
extending into the back of the head, are also amongst the earliest 
symptoms, produced probably by pressure upon the nervous trunks. 
Difficulty in swallowing, again, is often produced by pressure upon 
the oesophagus; and another remarkable effect of the pressure of 
aneurismal tumour is that upon the large veins, producing distension 
of the veins of the chest, neck, face, or even the upper extremities, 
sometimes giving rise to oedema of these parts. In other cases, again, 
there is atrophy, from the pressure reaching the thoracic duct. 

The above effects might, in the greater number of instances, be 
produced by any other tumour in the same situation, though it is 
one in which none is so likely to occur as aneurism. But besides 
these there are the effects produced upon the circulation generally, 
and more especially upon the arterial system. The first and most 
obvious impression must be upon the left ventricle, the sj^stole of 
which is more or less impeded by the obstruction in the aorta; for 



ANEURISM. 291 

even if there have not been sufficient coagula to obstruct the channel, 
the very fact of disease in the artery destroys that elasticity by which 
it assists in forwarding the current of the circulation, and conse- 
quently induces more or less hypertrophy and dilatation. The cur- 
rent along the arteries must also be disturbed by obstruction so near 
its commencement, and consequently we have a degree of thrill or 
splashing not unlike that produced by disease of the aortic valves, 
though in a less degree. In short, the effect upon the circulation is 
in general not unlike that of the latter affection. Besides this, how- 
ever, we may have great obstruction to the current either through 
the aorta, the innominata, the subclavian, or common carotids. This 
may arise either internally from the clot, or from the aneurismal sac 
pressing upon the artery from without. When the aorta itself is 
thus obstructed the pulse at each wrist will be similarly affected, so 
that it may be very small, and in some rare instances it has been 
wholly obliterated. When, however, the pressure is upon the large 
arteries, there will be a difference according to the side affected, and 
consequently the pulse at one wrist may be almost imperceptible, 
whilst that at the other remains nearly natural. 

The physical signs presented by the aneurismal tumour itself are 
generally pulsation and sound. The pulsation is, in most cases, 
expansile, that is to say, extending itself laterally as well as ante- 
riorly, and sychronous with the systole of the heart. There are, no 
doubt, exceptions to this rule, since the clot may be so large that the 
current which passes through the sac may not be sufficient to cause 
any perceptible expansion, and, in some cases, even any movement 
which can be detected by the hand. The sounds which may be heard 
by placing the stethoscope on the projecting part of the surface are 
in the majority of instances double, consisting of a first sound, which 
we call systolic, as accompanying the systole of the heart, though it 
in reality attends what might be termed the diastole of the aneurismal 
sac; and a second or diastolic sound, synchronous with the diastole 
of the heart, though with the systole of the aneurism. The first of 
the above murmurs is produced by the roughened condition of the 
artery, and the agitation of the current produced by the change in 
size which the current undergoes in passing from the artery into the 
sac. The diastolic, or second murmur, is to be referred to the exit 
of the blood produced by what may be termed the systole of the sac. 
The above are the sounds which are commonly heard, and which are 
obviously to be explained by this aneurismal condition; but it is 
evident that they must be liable to great modifications, and that 
many circumstances may interfere with their production. Thus the 
first, which is ordinarily the loudest, may be very feeble or altogether 
wanting, owing to the entrance to the orifice being very smooth ; and 
if, on the other hand, the exit be disturbed by moveable fibrine, the 
second or diastolic murmur will be rendered the loudest. If the 
action of the heart be very feeble, the orifices of the aneurism very 
free, the channel through the aneurism very smooth, or the pouch 
rendered incapable of distension by the deposition of fibrine, one or 
both murmurs may be absent. 



292 ANEURISM — ITS TREATMENT. 

From what lias been said, it must be inferred that the diagnosis of 
aneurism is often exceedingly obscure, as many of the signs often 
regarded as diagnostic may be absent, and, on the other hand, several 
may be simulated by other tumours. The early diagnosis of this 
affection has been admirably given by Dr. Addison: — "When the 
aneurismal swelling is such as to cause injurious pressure upon 
neighbouring parts, and interrupt the functions of particular organs, 
our apprehensions are likely to be awakened; and if we find the 
heart's action greatly disturbed, without our being able to trace it to 
any decided disease of the organ itself, or to sympathy with disease 
in other parts — if we observe the flow of blood passing to the descend- 
ing cava to be much obstructed — if we have indications of pressure 
upon the trachea and bronchi or upon the pneumogastric or recurrent 
nerve, producing hoarseness and feebleness of the voice, croupy 
cough and respiration, or symptoms of spasmodic asthma, or of 
spasm of the glottis — if there be anomalous symptoms of bronchitis, 
pneumonia, or haemoptysis — if deglutition be painful or so difficult 
that the patient is under the necessity of making a double effort 
before the meal will descend into the stomach — and if he complain 
of vague or severe rheumatic, lancinating, or grinding pains about the 
back of the neck, in the upper extremities, or shooting from the 
sternum to the sides, and towards the back, the existence of an 
aneurism becomes more than probable." 

In the management of aneurism our chief object should be to 
maintain the current of the circulation at the lowest possible volume; 
but at the same time the power of the circulation must not be much 
depressed; for if the latter effect be produced, there will, in the case 
of aneurismal dilatation, be a danger of promoting dilatation of the 
left ventricle, and it may be also of rendering the pouched artery 
more yielding ; and, in the case of a sacculated aneurism, of rendering 
the coagulum so loose as to be ineffective as a support to the weak- 
ened parietes of the sac. When there is much tenderness over the 
tumour a few leeches may be from time to time applied. Eepeated 
very small venesections are not, as Dr. Chevers observes, so objec- 
tionable in the case of aortic aneurism as in that of ordinary heart 
disease ; but when these are employed mild tonics should be at the 
same time exhibited. The important object, however, of obtaining 
the conditions most favourable for the relief of the disease, namely, 
a moderate volume of circulating fluid with a good proportion of 
fibrine, will be best obtained by a scanty use of fluids, a nutritious 
diet, the employment of purgatives, and occasionally diuretics (the 
former being to be preferred as less likely to promote a spansemic 
condition), and by the use of gentle tonics. Of the other class of 
medicines zinc is one of the most eligible, from its not producing any 
stimulating effect upon the heart, which is sometimes the case with 
iron. The senega also, which we have already recommended in dis- 
ease of the aortic orifice, will often be of great service; allaying 
excitement without depressing the vital powers, it may be combined 
with a diuretic, thus (F. 44). A pure air is of the greatest import- 
ance, since, under the necessity for rest, it presents the means of 
maintaining the plastic power of the blood. 



DISEASES OF THE LIVER. 293 



XV. 

DISEASES OF THE LIVER AND ITS APPENDAGES. 

Before proceeding to the consideration of the diseases of the 
alimentary canal, we pass, as it were, along the course of the circula- 
tion to those of the liver ; the condition and activity of which are so 
intimately connected with those of the thoracic viscera. 

Congestion of the liver is among the most frequent of its morbid 
conditions. This may arise in various ways ; and as the probable 
course of the disease will depend mainly upon the cause from which 
it has arisen, and our treatment must also be in a great measure 
regulated by our knowledge of it, we may speak of the different 
forms of congestion in the order of their causes. 

The most common cause of congestion of the liver is, obstruction 
to the exit of the blood from the venae cavae hepaticae, arising, in the 
majority of instances, from disease within the chest inducing obstruc- 
tion to the circulation through the right heart ; though it may also 
be produced by other causes, as obstruction in the vein itself. The 
first consequence of this is engorgement and congestion of the branches 
of the venae cavae hepaticae, constituting what was termed by Dr. 
Kiernan hepatic-venous congestion, giving to the liver a mottled 
appearance (the earliest presented in the so-called nutmeg change or 
degeneration), the centre of the lobules only, becoming red from 
congestion of the hepatic twigs originating from them, whilst their 
margins remain pale. This congestion must, of course, spread itself 
in a direction contrary to that of the circulation, that is to say, from 
the heart, or into the capillaries communicating with the twigs of the 
branches of the portal vein, by which the dark-red colour spreads 
towards the circumference of the lobules : so that where the twigs of 
one lobule are continuous with those of a contiguous one, the dark 
colour extends from one to the other. The liver will still present a 
mottled appearance ; though the deep-red colour will preponderate 
more than in the former stage. When this congestion has been long 
continued, the liver becomes sensibly enlarged, its margin descending- 
two or three inches below that of the ribs. 

The second stage of the mechanical or hepatic- venous congestion 
is rarely attained unless there be a persistent cause of obstruction to 
the return of the blood through the cava. The branches of the portal 
vein likewise become congested, and the secretion of bile impeded, 
the effect of which is that those parts which are not reddened by 
the congestion become tinged with yellow by the retention of bile. 
When this is the case, the liver becomes still more enlarged, often 
descending as low as the crest of the ilium, and the complexion of 
the patient becomes dusky, and the conjunctivae tinged ; the urine 
also is high-coloured, loaded with lithates and purpurine, and scanty. 
The alvine evacuations are sometimes pale, but more frequently dark 



294 SECONDARY CONGESTION — TREATMENT. 

or green. This state of the hepatic circulation will often give rise to 
effusion into the peritoneum ; oedema of the lower extremities is a 
frequent concomitant, though it is produced directly by the disease 
in the chest, rather than through the medium of the liver. 

It is stated by Dr. Budd, that this condition of liver is attended by 
little or no pain beyond the feeling of weight and distension in the 
right hypochondrium ; and it is probable that such is in most in- 
stances the case; though 1 it not uncommonly happens, that where, 
as in cases of acute bronchitis supervening upon chronic, or upon 
valvular disease of the heart, the liver becomes rapidly congested, 
there is intense pain across the epigastrium, especially upon the right 
side ; this can hardly be explained otherwise than by the tension of 
the proper and peritoneal coats of the liver, from the sudden enlarge- 
ment of the organ. 

The diagnosis of this form of congestion, — the hepatic-venous 
congestion of the liver, — must rest mainly upon our knowledge of 
the state of the circulation within the chest. When, therefore, there 
is enlargement of the liver (to be detected by percussion or manipula- 
tion), with scanty urine, of high specific gravity, or depositing pur- 
purine or urates ; and when at the same time there is disease of the 
heart, or of the bronchial tubes, or such as has been already shown 
to produce engorgement of the liver, we may infer that there is the 
mechanical or hepatic-venous congestion : if also we have reason to 
suspect that obstruction exists in the ascending cava itself, extending 
as high as the entrance of the hepatic veins, we may expect a similar 
result. We lay some stress upon the diagnosis of this form of liver 
disease, and upon the necessity of referring it to its true cause ; be- 
cause, when the enlargement of this organ is detected during life, or 
the changed appearance produced by the congestion noticed after 
death, there is still, in the minds of many practitioners, a tendency 
to regard the secondary and often more palpable lesion as the primary 
and causative, and not, as it really is, as the secondary one. 

The prognosis of this disease, like the diagnosis, must depend upon 
that of the primary lesion ; but at the same time it must be remem- 
bered that its existence is a proof of the serious nature of the latter, 
and tends to render the prognosis more unfavourable. When the 
cause of the venous obstruction is capable of subsidence or removal, 
as in the case of bronchitis, the congested liver will, with the repara- 
tion of the original lesion, diminish in size, and return to its natural 
condition. 

The treatment of the hepatic, in addition to that which is directed 
to the primary affection, must consist of cupping at the margin of 
the liver, diuretics, and purgatives. The latter are the most im- 
portant ; since, for reasons already explained (p. 242), the former class 
of medicines, when the circulation through the liver is impeded, will 
often, and that too in the severest cases, fail in their operation. 

Where there is nothing to forbid it in the general condition of the 
patient, about eight ounces of blood may be taken from the margin 
of the ribs, and the bowels freely relieved by a few grains of calomel 
with jalap, followed either after a few hours, or the next morning, 



PRIMAKY CONGESTION. 295 

by tlie aperient draught of tartrate of potass and manna (F. 13); and 
subsequently one of the diuretic mixtures may be regularly ad- 
ministered. By these means we may frequently relieve the congestion 
of the liver, and diminish the obstruction in the chest from which it 
originated. 

There is, as pointed out by Dr. Budd, another form of congestion 
of the liver, which, though it may be produced in extreme cases of 
that just described, is essentially of a more active character, and 
arises from over-stimulation of the secreting structure. It is not 
improbable that this form patakes more of the " portal- venous-con- 
gestion" of Mr. Kiernan, though this in its simplest condition is 
stated by that gentleman to be extremely rare. Certain, however, it 
is, that congestion of the liver does occur in persons in whom there 
is not mechanical obstruction sufficient to account for its presence, 
and in whom its probable exciting cause is in the blood of the portal 
vein, which is overcharged with alcohol or with the products of 
imperfect digestion. 

The anatomical change produced in the liver by the portal-venous 
congestion consists (according to Mr. Kiernan) in an increased injec- 
tion of the twigs of the portal vein ramifying around the lobules, and 
of the capillaries in the margin of the lobules, leaving the central 
parts pale and uninjected; thus we have a pale mottling upon a red 
ground, as in the second stage of hepatic- venous congestion, though, 
according to Mr. Kiernan, the red is not of so deep a tint. 

Another cause of active congestion is the absorption of unwhole- 
some exhalation, of which the marsh or ague poison has notoriously 
the effect of producing congestion and enlargement of the liver. 

The diagnosis of this form of congestion of the liver is more obscure 
than of the other, which depends upon mechanical causes: in the 
absence of such cause, where there is enlargement of the liver, scanty 
and dark-coloured urine, a jaundiced complexion and conjunctivae, 
evacuations rather pale, or wanting the bright colour of healthy bile ; 
and where there is a dull weight without acute pain in the region of 
the liver, with pain in the right shoulder or between the scapulas, we 
may infer this form of disease of the liver. 

The prognosis of primary congestion of the liver is doubtful ; since, 
owing to the state of constitution in which it ordinarily occurs there 
is but little tolerance of the means recommended above for relieving 
the venous congestion Of the organ ; and there is much danger of 
typhoid symptoms with extreme exhaustion supervening, as well as 
of coma from the retained secretion in the blood. The unfavourable 
symptoms are, a continuance of the icterode appearance, especially if 
purpura or oedema be superadded, stupor, jactitation, delirium, scanty 
urine, rapid and feeble pulse, with a brownish or dry tongue. The 
subsidence of the jaundiced appearance, the absence of cerebral dis- 
turbance, and an abundance of urine, with a reappearance of healthy 
bile in the evacuations, are favourable. It is possible that the un- 
favourable symptoms may arise in this disease from the obliteration 
or destruction of the secreting cells, giving rise to the fatal form of 



296 ITS TEE AT MEN T. 

jaundice attributed by Dr. Budd to that cause, and which will be 
hereafter described. 

The treatment of primary congestion of the liver must consist, in 
cases where the condition of the patient does not forbid it, of local 
depletion, mercurial and saline purgatives, and diuretics. 

Where we have reason to suspect the disease to have arisen from 
the too copious use of alcoholic drinks, we must be very guarded in 
the abstraction of blood, and when the pulse is very compressible, or 
there is any tremor of the tongue or limbs, we must not venture 
upon it. Otherwise, about six or eight ounces from the region of 
the liver will materially promote the cure of the disease. If, as is 
sometimes the case, the bowels are irritable, we must, of course, 
abstain from active purgation ; but even when such is the case, about 
four grains of hydr. cum cret., followed by two or three drachms of 
castor oil, guarded, if necessary, by as many minims of laudanum, 
will generally be borne, and may have the effect of removing irrita- 
ting matter from the alimentary canal. When this is not the case, a 
combination of Pil. Hydr. and Pil. Coloc. co. may be administered 
every night or every other night, according to circumstances, and 
the sulphate of magnesia, with the carbonate once or twice a-day. 
It may be well here to insist upon not giving mercury otherwise 
than as a purgative, and always so to combine it as to insure its purga- 
tive action ; for there is no more pernicious practice than that of 
administering it indiscriminately in all diseases of the liver. If 
mercury have a direct cholagogue action when absorbed into the 
circulation, it cannot fail, when so absorbed, to increase the hyper- 
amia which we wish to subdue ; but as it certainly has a tendency to 
diminish the cohesion of the tissues, a tendency which already exists 
in the majority of instances of retained secretion, we have a still 
stronger reason against its use, except as a purgative. When, how- 
ever, it is so employed, it excites the secretion from the lining mem- 
brane of the small intestines, and by stimulating the part into which 
the bile is to be poured, affords the only safe means of relieving 
congestion of the secreting organ. 

After the action of the bowels has been well established, or even 
in the intervals between the aperients, we may give the citrate of 
potass draught in effervescene, with about 3ss. of sp. seth. nit. ; to 
which may be added, when there is no sickness or great prostration, 
about fifteen minims of antimonial wine. When the symptoms 
begin to assume a more chronic character, the taraxacum may be 
used in combination with some diuretic (F. 48) * Should delirium 

* (48) R. Ext. Taraxaci, 9 i. 
Sp. iEth. nit. 3 ss. 
Infus. Scoparii, g xss. 
Ft. Haust. ; to be taken three times a-day. 
To this there may be added, when the urine is not highly acid, Acid. Nit. dil. 3 ss. 

Or, R. Pot. Acetat. J} j. 

Sp. iEth. nit. 3 ss. 

Decoct. Scoparii co. § j. 

Ft. Haust. ; to be taken three times a-day. 



INFLAMMATION OF THE LIVER. 297 

or coma supervene, a blister may be applied to the neck ; and when, 
as will sometimes be the case, the tongue becomes brown, or the 
pulse very feeble, or there are other signs of sinking, wine and stimu- 
lants must be freely administered ; and this must be done earlier in 
those cases where they have previously been too largely used. 

From the congestive we pass to the inflammatory diseases of the 
liver : of this we cannot adopt a better division than that given in 
the admirable work of Dr. Budd, into the — 

I. Suppurative inflammation, or that which tends to suppuration 
and abscess. 

II. Gangrenous inflammation. 

III. Adhesive inflammation, or that which causes effusion of 
coagulable lymph. 

TV. Inflammation of the veins of the liver. 
Y. Inflammation of the gall-bladder and ducts. 

I. Suppurative inflammation of the liver : — 

Of this form of inflammation, the causes appear to be (1) mechani- 
cal injury; (2) suppurative inflammation of a vein, and consequent 
infection of the blood with pus ; these abscesses are not, as used to 
be supposed, deposits of pus from the blood transuding through the 
walls of a vessel ; but the product of a suppuration induced in the 
first instance by the lodgement of a pus globule in one of the capil- 
laries of the part. 

From the above cause of suppuration, the liver becomes affected 
only in common with other structures of the body ; and is so affected 
next, in point of frequency, to the lungs, as being the next in regard 
to the quantity of venous blood passing through it, and the slowness 
of its progress; there is, however, another cause of suppuration 
which appears specially to affect the liver, and that is, ulceration of 
those parts the veins of which return their blood to the portal vein, 
to be thence transmitted through the capillaries of the liver : as, for 
instance, the intestines, stomach, gall-bladder, or gall-ducts. Of these 
conditions, that which is most commonly associated with abscess of 
the liver, and is in fact its most frequent cause, is dysentery. 

The anatomical changes produced by suppurative inflammation of 
the liver, are, first, redness and softening ; next, puriform infiltration, 
which is, however, of very short duration ; and, thirdly, suppuration, 
or abscess. This inflammation, in the words of Dr. Budd, " com- 
mences in the lobular substance of the liver, and is often confined to 
it ; the capsule of the liver, the trunks, the vessels, and of the ducts 
being perfectly healthy. But if the inflamed part reach the surface 
of the liver, adhesive inflammation is generally set up in the portion 
of the capsule immediately above it, and coagulable lymph is poured 
out, which causes permanent adhesion between that portion of the . 
liver, and the parts with which it is in contact." 

Abscesses in the liver vary in size from that of a pea to that of a 
cavity containing several pints ; the contents of these abscesses are 
most commonly like those of ordinary phlegmonous abscesses, unless, 
as Dr. Budd observes, when, from communication with the lung, it 



298 SUPPURATIVE INFLAMMATION 

becomes decomposed and foetid from the admission of air. In ab- 
scesses occurring in subjects with but little plastic power, and in 
whom the disease is for the most part quickly fatal, there is no 
stroma or fibrinous lining to the cavity ; but in the majority of cases, 
it is lined by a layer of false membrane, like a phlegmonous abscess. 
An abscess of this kind may remain for a long time stationary ; but 
in most cases it follows the usual course, making its way towards 
the surface, ultimately emptying itself — it may be into the peritoneal 
cavity, and producing speedy death from peritonitis, though this 
seldoms happens — more commonly adhesion is established between 
the liver and some adjoining viscus, as the stomach or colon, with 
which the abscess ultimately communicates by ulceration, or it finds 
its way through the diaphragm in a similar manner into the lungs, 
after which its contents are expectorated — or it reaches the surface, 
and points externally. 

It may be very easy to lay down symptoms as diagnostic of ab- 
scess of the liver ; but actual clinical experience teaches us that the 
diagnosis of this disease which, to say the least, is not common in 
this climate, is obscure in the highest degree. Dr. Budd, and we 
need cite no higher authority, says that " physicians who have had 
most experience in this disease confess their inability, in many cases, 
to distinguish it from other diseases of the liver ; and in some cases 
even to pronounce that the liver is the seat of disease at all,"* 

The cases in which the symptoms are most closely marked, are 
those in which the suppuration is the effect of a blow, or other direct 
injury. This usually takes place on the convex surface. " There is 
pain and tenderness in the region of the liver, and a sense of fulness 
and resistance under the false ribs, from increased size of the organ. 
The liver becomes enlarged, and if the abdomen be flaccid, and the 
intestines empty, its edge can be felt some inches below its natural 
limit. The secretion of bile may be suppressed or deficient, and the 
patient jaundiced. In addition to these symptoms, which may be 
called special, from their pointing to the liver as the seat of disease, 
there soon appear, as in simple inflammation of other organs, the 
general symptoms of inflammatory fever ; the pulse is frequent and 
full, the skin hot, the tongue furred and yellowish ; appetite is alto- 
gether absent, or much diminished ; the patient is thirsty, and there 
is occasionally vomiting of bilious matter ; while the urine is scanty, 
high-coloured, and deposits a red sediment."f 

When the above special and general symptoms concur after injury 
over the region of the liver, and there is no evidence of disease of 
the lung or pleura, we may infer suppurative inflammation of the 
liver. But, as Dr. Budd very justly adds, the liver is so well 
shielded by the ribs, that the disease is seldom caused in this way. 

When, as is more frequently the case, suppurative inflammation 
occurs as the effect of puriform infection of the blood from remote 
injuries, surgical operations, or phlebitis, we can receive no assistance 
from the constitutional symptoms, since they exist beforehand, 

* Budd on Diseases of the Liver. f Ibid. 



OF THE LIVER. 299 

owing to the primary lesion ; and we can only infer the existence of 
this affection from the special symptoms, pain in the region of the 
liver, and jaundice occurring in the midst of the general disorder. 
But even these may be absent, and then, as Dr. Budd says, " the 
abscesses in the liver can be discovered only after the death of the 
patient." 

The diagnosis is not much, more obvions in the case of abscess of 
the liver occurring during dysentery; it must rest mainly upon the 
special symptoms, pain and tenderness in the region of the liver, ten- 
sion in the right hypochondrium, and jaundice; these symptoms may 
all arise under other circumstances, as from obstruction or inflamma- 
tion of the gall-ducts, but when they arise in the course of an attack of 
acute dysentery, or in acute supervening upon chronic, the suspicion 
should be entertained of suppurative inflammation and abscess of the 
liver. 

It may happen, however, that suppuration occurs without any of 
these symptoms, since this form of inflammation causes but little 
enlargement, at least before the formation of pus, and if there be no 
great extent of the organ involved, the enlargement will be scarcely 
perceptible. And as regards jaundice, we know that a portion only 
of the liver (as is also the case with the lungs and kidneys) is often 
sufficient for the depuration of the blood, and consequently when the 
inflammation is partial, there need be no jaundice. Again, we know 
that the parenchymata generally are not sensitive structures, and that 
when inflammation is deep-seated, it may go on to suppuration with- 
out being attended by any considerable amount of pain. Besides the 
above general and special symptoms, there are others occasionally 
observed, and which when they do occur, often continue after the 
feverish symptoms have passed; these symptoms are pain in the right 
shoulder, vomiting, a short dry cough, and permanent rigidity of the 
muscles of the abdominal parietes, but especially of the right rectus 
muscle.* Pain in the right shoulder occurred to Dr. Budd in five 
cases out of fifteen ; of three which occurred to the author, it was 
absent in two, and present in the other. In one of Dr. Budd's cases, 
where the abscess was upon the convex surface of the liver, the pain 
in the right shoulder, which was intense, was relieved when the 
abscess was opened. Dr. Budd also confirms the statement of Dr. 
Annesley, that pain in the right shoulder is a sure sign of the abscess 
being in the right lobe. 

When hepatic abscess is the result of phlebitis, the more urgent 
symptoms are those of puriform infection generally, and the suppura 
tion is as extensive in the lungs as in the liver, or more so; the 
patient passes rapidly into a typhoid state, and there is no oppor- 
tunity for active treatment. Under such circumstances, the best that 
can be done is to support the powers with the liberal use of wine, and 
serpentary and ammonia, and sedulously to apply hot fomentations to 
the affected part. 

When the suppurative inflammation arises either from an ulcer, 

* Budd, op. citat. 



300 GAN GEE NOUS INFLAMMATION. 

or from ulceration in those parts from which the blood is returned 
through the portal vein, the suppuration being confined to the liver, 
and the system generally not infected with the poison, there is oppor- 
tunity at the commencement for more active measures: blood-letting 
may even be ventured upon when the pulse is full and hard, but, as a 
general rule, cupping at the margin of the ribs on the right side is to 
be preferred. There will always, no doubt, be some difficulty, from 
the obscurity of the diagnosis, but the same measures will be, to say 
the least, harmless, when the same symptoms arise from inflamma- 
tion in any neighbouring organ. As regards the use of mercury, 
there can be little doubt that, except as an adjunct to an aperient, its 
exhibition in any stage of this disease must be positively injurious, 
since, in so far as it acts as a stimulant to the organ, its use is con- 
trary to that most important rule in practice, of avoiding all excite- 
ment of an inflamed part, and when suppuration has taken place, it 
must have the same ill effect as in all suppurative diseases. In reply 
to the question of the expediency of opening an abscess of the liver, 
Dr. Budd very justly condemns the practice, except when it is evi- 
dent from circumscribed oedema, or a slight blush on the skin, that 
union has taken place between the integument and the abscess. 

In more chronic cases, the best practice to pursue is the use of 
gentle laxatives, as decot. aloes co. with rhubarb (F. 42), and when 
there is a tinge on the skin and conjunctivae, the use of nitro-muriatic 
acid which taraxacum. 

II. Gangrene of the liver is an exceedingly rare affection, so much 
so as to be of but little importance in a practical point of view; and 
is chiefly deserving of notice from the circumstance of portions of the 
organ of a dark-green colour, with a very putrid offensive odour, 
being observed near the margin of the abscesses that have not be- 
come encysted, being frequently regarded as gangrenous ; though the 
appearance is in reality the defect of decomposition, and also that 
gangrene does sometimes affect this organ. It never, according to 
the best authorities, occurs without gangrene of some other part. 

III. We have already seen that adhesive inflammation may take 
place in the portion of the liver contiguous to an abscess, and the 
soft albuminous matter which lines the latter be again enclosed by a 
deeper layer of fibrinous lymph, which acquires a greater degree of 
hardness according to the age of the abscess; the adhesive inflamma- 
tion in this case being confined to the neighbourhood of the abscess 
which excited it, though it may extend to the capsule, and to the 
peritoneal coat of the organ, and to neighbouring viscera. And we 
have already alluded to the fact of fibrinous lymph effused on the 
surface of the liver, falling down into the abdomen or pelvis, and 
setting up adhesions between other viscera. Adhesive inflammation 
of the liver may also be excited around hydatid tumours, and some- 
times, though rarely, around cancerous growths. 

The capsule of the liver may, however, be extensively inflamed in 
connection with deep-seated adhesive inflammation occurring, to a 
greater or less extent, in the substance of the organ, the lymph being 
effused almost entirely in the areolar tissue which accompanies the 



ADHESIVE INFLAMMATION. 301 

portal veins. Sometimes, according to Dr. Budd, the effusion is 
limited to larger branches, which are surrounded by it to the distance 
in some parts of half an inch; these branches, however, remaining 
pervious, but some of the twigs which arise from them are obliter- 
ated, and the parts of the liver supplied by them atrophied, though 
the other portions of the liver are apparently not affected : the neigh- 
bouring portion of the capsules is also puckered, and there are 
generally adhesions to neighbouring organs. It more commonly 
happens, however, that the effusion of fibrinous lymph extends to 
the areolar tissue forming the nidus of the small twigs between the 
lobules. The subsequent contraction of the lymph strangulates the 
vessels and ducts, puckers the capsule, giving to the surface of the 
liver the uneven appearance commonly known as hobnailed. The 
organ throughout is rendered paler than natural by the white fib- 
rinous matter, and by the diminished quantity of blood caused by 
the strangulation of the vessels, whilst it is rendered yellowish by 
biliary matter detained in the cells. This condition gives to the 
organ the appearance of impure bees-wax, whence the disease in 
question has received the name of cirrhosis, from the French authors. 
In other cases the contrast between the yellow biliary matter in the 
cells and the surrounding fibrous tissues is more marked, owing to 
the quantity of the latter being much greater, and by its stronger 
contraction drawing the liver in nodules, which appear like peas 
dispersed through the surface of the organ. Sometimes there is, in 
addition to this change, the deposition of oil-globules in the lobules, 
swelling out the latter, and rendering the organ more nudular at the 
same time that it makes the lobular tissue softer. 

The anatomical condition upon which this cirrhosis of the liver 
depends being in the first instance the effusion of lymph — of which 
the serum is absorbed, and the flbrine ultimately contracts — it fol- 
lows, that the size of this organ so affected must undergo considerable 
variations, being in the first instance somewhat enlarged, and when 
fatty degeneration coincides with the cirrhosis, considerably so ; but 
as the contraction of the fibrinous effusion goes on it becomes smaller, 
and is at last reduced considerably below the natural size and weight. 

The cause of the inflammation inducing the changes above described 
is over-stimulation of the organ, this over-stimulation being in most 
instances produced by the character of the blood in the portal vein. 
The most palpable, as well as frequent examples of this, are found in 
the spirit-drinkers, unfortunately too numerous in our large towns ; 
and it is remarkable that spirit-drinking produces the disease more 
speedily and certainly than does the use of alcohol in any other form, 
as wine or beer ; but hot climates, or even long-continued exposure to 
heat in the pursuit of various occupations, will greatly promote, if 
not induce, the same result, probably b}^ calling into requisition the 
supplementary function of the liver by diminished activity of the 
lungs. A stimulating diet, confined air, and want of exercise, pro- 
mote the same result. This was remarkably exemplified in two 
fawns who were kept for some time at the back of Guy's Hospital, 
often getting fed upon linseed meal and other matters readily under- 



302 CIRRHOSIS OF THE LIVER. 

going fermentation, and of course using (for thera) but little exercise, 
and living in an impure atmosphere. These creatures both died of 
ascites from cirrhosis of the liver. 

Cirrhosis of the liver usually comes on insidiously, and the patient 
seldom comes under treatment so much for the disease in the liver 
itself as for the effects produced upon the rest of the system. In 
some cases, however, there is a more rapid onset, and there are 
symptoms indicative of active inflammation, combined with those of 
rapid diminution of the secretion of bile. There is loss of appetite, 
nausea, and, it may be, sickness, pains in the limbs, and other symp- 
toms of pyrexia, the skin and conjunctivae become more or less 
tinged with bile, the urine high-coloured and loaded with lithates; 
there are pain and tenderness in the region of the liver, and the 
organ may be felt below the margin of the ribs. 

When these acute symptoms do not present themselves at first, or 
when they have been subdued by treatment, or have spontaneously 
subsided, the patient makes no very distinct complaint, but gradu- 
ally loses flesh and strength, and his skin becomes sallow and dry, 
the countenance sunken and dingy. After some time, generally 
several weeks or months, the effused lymph contracting, the circula- 
tion through the portal vessels is obstructed, and the escape of bile 
is probably at the same time impeded ; the effect of which must be 
both scanty secretion and delayed excretion. In the mean time the 
fibrinous lymph goes on contracting, and the liver from being larger 
than natural, becomes smaller, in some cases exceedingly so, and the 
obstruction to the passage both of blood and bile through their proper 
vessels is almost closed. The effect of the closure of the portal ves- 
sels is obvious in various ways. There is a general exudation of 
serum from the extreme branches of the veins converging to form 
the vena portae, and the consequence is effusion into the peritoneal 
cavity. This goes on increasing, generally without pain or tender- 
ness. The amount to which this fluid increases is often such as to 
press up the diaphragm and impede the respiration, and also by 
pressure upon the ascending cava, to divert the returning blood into 
the superficial veins, and cause great enlargement of those on the 
surface of the abdomen; these are still further distended, owing to a 
portion of the portal blood finding its way by this course to the right 
side of the heart, having access to these veins from the hemorrhoidal 
branches of the superior mesenteric vein, through the branches of the 
internal iliac which anastomose freely with the former. From the 
same cause the lower extremities become anasarcous, but not the 
upper or the face, which remains shrunken throughout. The portal 
obstruction likewise causes engorgement of the venous branches in 
the mucous membrane of the alimentary canal, resulting in haemor- 
rhage from the stomach and bowels. 

The obstructed circulation through the portal system also prevents 
the absorption of fluid into the general circulation, and consequently 
the urine becomes scanty. This diminished absorption must, no 
doubt, induce a scanty supply to the whole system, and render the 
process of waste and repair much less, which may account for there 



CIEEHOSIS OF THE LIVEE. 303 

not being more obvious ill effects from the diminished secretion of 
bile and urine. The blood is, however, materially disordered, as may 
be seen by the general tendency to haemorrhage, spots of purpura 
or ecchymosis being rarely absent sooner or later, and besides the 
haemorrhage above noticed, which are due merely to mechanical 
obstruction, epistaxis, and bleeding from the mouth or gums, or from 
leech-bites, or the wounds of scarificators in cupping, are of common 
occurrence. 

The diagnosis of this disease may be, in the onset, somewhat 
obscure, but the sallowness, feverishness, dull pain in the region of 
the liver, with a history of the use of spirits, where a correct account 
can be obtained, are pretty conclusive evidence of this disease, even 
before any of its more characteristic signs have begun to show them- 
selves. But when, by the progress of the disease, we have the known 
results of obstructed circulation through the liver, such as ascites, 
scanty urine, and subsequent anasarca of the lower extremities, the 
diagnosis, especially in male subjects, is comparatively easy, espe- 
cially when we can get an insight into the history of the patient. 
The only diseases with which it can be confounded are enlargement 
of the spleen, chronic peritonitis, malignant disease of the liver or 
omentum, or malignant growths obstructing the portal circulation ; 
and in the female ovarian dropsy. 

From enlargement of the spleen it may be distinguished by the 
previous history, by the absence of tumour under the left hypochon- 
drium, aided by the persistence of the ascites, which often in enlarge- 
ment of the spleen, subsides, leaving the tumour, which may be 
recognised by its shape and the notch at its anterior edge. In chronic 
peritonitis there is often more tenseness of the abdominal walls, and 
the fluctuation is not so distinct. This disease often occurs in con- 
nexion with tuberculosis, of which we may find symptoms in other 
parts of the body. The hollow viscera, too, in hepatic ascites, will 
always float to the portion of the abdomen which is uppermost, 
according to the position of the patient, so that we have this part 
resonant and the rest of the belly dull upon percussion. This free 
movement cannot take place in peritonitis, owing to adhesions of the 
viscera to each other, and contraction of the mesentery; and con- 
sequently, there will not be the circumscribed area of resonance 
which we find in simple ascites, though the general resonance may 
be greater. 

In cancer, of the liver or peritoneum, the effusion is rarely so great, 
the complexion has more of a dingy whiteness than of the sallowness 
of hepatic disease. In most forms of cancer of the liver we can feel 
the enlarged organ; it is nodulous, and the enlargement generally 
increases as the disease advances. The emaciation too, and general 
progress of the disease is more rapid ; and there is generally evidence 
of the same disease elsewhere ; and cancer is not a disease induced 
by intemperance. Yery similar constitutional signs, with more dif- 
fused pain and tenderness in the abdomen, and a nodulous tumour 
in the epigastrium, which may be mistaken for a cancerous, but not 



304 CIRRHOSIS OF THE LIVER. 

very readily for a cirrliose liver, will enable us to distinguish cancer 
of the omentum from the latter disease. 

There is a form of probably malignant disease existing in the 
ascending cava, involving the kidney, and extending almost into the 
right auricle, described in the second volume of the second series of 
Guy's Hospital Eeports, which also produces great ascites, and even 
greater enlargement of the superficial abdominal veins, than does 
cirrhosis, from which it is with difficulty distinguished ; but the diag- 
nosis has been effected, and may be so by carefully considering all 
the effects which would ensue from simultaneous obstruction of the 
ascending and hepatic cavae. 

Ovarian dropsy is another source of difficulty, especially when 
there is a very large cyst ; the previous history will, however, do 
much to guide us ; added to which that, the swelling is generally said 
to have commenced rather more on one side than the other, and the 
dropsy being encysted, the intestines are pushed on one side, and do 
not float up, and give a hollow sound in the centre of the abdomen, 
as when the fluid is in the general cavity. Hydatids, though fre- 
quently producing great abdominal enlargement, need never be 
mistaken for ascites. 

In the treatment of cirrhosis we must act upon the knowledge 
that it is primarily an inflammatory affection of the liver ; that until 
the effused fibrinous lymph has become organised and begun to 
contract, the indications are to arrest the inflammation, and, if possi- 
ble, promote the absorption of the inflammatory effusion; but that 
subsequently the organ is spoiled, although the disease may be at an 
end; and therefore we can only palliate its effects, namely, obstructed 
portal circulation and diminished or almost obliterated function of 
the liver. 

In the commencement local depletion may be employed, but with 
great care, for we have to do with those who, from previous intem- 
perance, are intolerant of loss of blood, and liable to delirium tremens 
from its being carried too far. Cupping, however, of the liver to 
about eight ounces may be tried, and repeated once or twice if well 
borne. Saline purgatives, as the sulphate with the carbonate of 
magnesia, may be used at the same time, and a grain of calomel with 
half a grain of opium and one-sixth of a grain of tartar emetic, night 
and morning ; but the mercury is to be used at first only in small 
doses, and with a view to arresting plastic inflammation, not as a 
stimulant to the liver, for in so far as it has this effect it is mis- 
chievous. When, however, the febrile symptoms have subsided, we 
may use the mercury a little more, with a view to its specific effects, 
but still very guardedly ; and iodide of potassium is to be preferred 
in broken constitutions. The conium and blue pill (F. 52) may be 
used three times a- day. The saline aperients, if necessary, and iodide 
of potassium in two-grain doses, should be substituted for the blue 
pill as soon as the gums are the least affected, and iodine ointment 
may be rubbed into the right hypochondrium. 

IY. The veins of the liver are liable to inflammation both of the 
suppurative and plastic kind: of the former, the symptoms are not 



INFLAMMATION OF THE GALL-DUCTS. 305 

unlike those of hepatic abscess; of the latter, they are even still more 
obscure and uncertain. 

V. The mucous membrane of the hepatic system, like that in 
other regions of the body, is liable to different varieties of inflamma- 
tion : these are divided by Dr. Budd, in accordance with the analogy 
of the same membrane in other organs, into 1, catarrhal; 2, suppura- 
tive ; 3, croupal or plastic ; and 4, ulcerative or mucous inflammation : 
and it is not improbable that this " bronchitis of the liver" may play 
as important a part in the diseases of the biliary apparatus, as does 
bronchitis in those of the respiration. 

1. Catarrhal inflammation is, if we may judge from the analogy of 
other mucous membranes, most probably not an uncommon occur- 
rence, and may perhaps account for many of the cases of simple 
jaundice which we meet with in practice ; and the symptoms which 
we might expect to arise from such an affection would be slight 
pyrexia, dull pain in the right hypochondrium, and jaundice. 

2. In severe cases the secretion of the mucous lining of the ducts 
becomes puriform, the matter secreted being often of a greasy cha- 
racter, like pus which has been treated with an alkali, at the same 
time that it may be coloured by the bile. The symptoms are not 
very unlike what might be supposed to arise from an abscess in the 
liver. 

The inflammation of the ducts may, by the turgescence of the sub- 
mucous areolar tissue to which it gives rise, cause obstruction of the 
canal, as may readily be supposed when the narrowness of the canal 
is considered. When this obstruction affects the common duct there 
will be pain in that situation ; the liver will be gorged with bile, and 
jaundice will ensue. It will also not uncommonly happen that a 
pyriform tumour presents itself in the right hypochondrium, which 
is the distended gall-bladder. If the inflammation involve only the 
hepatic duct, the symptoms would be much the same, but there 
would be no enlargement of the gall-bladder ; but it does not neces- 
sarily follow that if the cystic duct be obstructed there need be none, 
since if, as is not unlikely, there be at the same time mucous inflam- 
mation of that sac, or if it be subjected to any other cause of irrita- 
tion, its own. secretion will be very considerable, and having no 
outlet will go on accumulating to an amount scarcely credible. In 
a patient of Dr. Babington's, at Guy's Hospital, the cystic duct had 
become obstructed, and the gall-bladder contained a quantity of thin 
mucus, which nearly filled a washhand-basin. The fact of the gall- 
bladder being capable of distension by its own secretion should be 
remembered as aiding diagnosis, and as tending to correct some 
erroneous inferences which may be drawn when it is found full upon 
examination after death. 

3. Plastic inflammation of the mucous lining of the biliary pas- 
sages is a very rare occurrence, and one with the clinical history of 
which we are unacquainted. 

4. Ulceration of the gall-bladder and biliary ducts is perhaps 
among the most common forms of inflammation of those structures, 
and may be induced by various causes, though the symptoms espooi- 

20 



306 INFLAMMATION OF THE GALL-DUCTS. 

ally referable to the lesion itself are, as might have been anticipated, 
by no means well defined. Dr. Bndd remarks that it has been 
noticed by several observers as one of the anatomical changes 
observed after death from remittent fever; and we have onrselves 
noticed it on more than one occasion in subjects who had died with 
typhus fever ; in one instance the peritoneal coat, which had been 
laid bare by the ulceration, gave way in gently lifting the gall-blad- 
der. It is also very apt to be excited in those who have previously 
suffered from disease in the same situation. 

Ulceration of the gall-bladder or ducts may, by perforating the 
peritoneum, allow the escape of the contents into the cavity of that 
membrane, giving rise to puriform peritonitis, which is speedily 
fatal. If indeed there have been closure of the cystic duct, and the 
gall-bladder, as before noticed, contain only the mucus secreted by 
its lining membrane, the escape being more gradual, and the extra- 
vasated matter not so intensely irritating, the extravasation may be 
circumscribed by adhesion. And the same will happen when the 
ulceration is set up by gall-stones, in which case the adhesion com- 
monly precedes the perforation, the bladder or duct becoming adhe- 
rent to some adjacent part, often the duodenum or colon, by which 
means the gall-stone passes into the intestinal canal. An ulcer in a 
large duct may find its way into a neighbouring branch of the portal 
vein, and then the consequences are most disastrous — bile as well as 
pus becoming mixed with the blood. 

The symptoms which precede the ulceration are probably pain, 
loss of appetite, thirst, and some degree of fever, with weight and 
heat at the epigastrium, and, when the inflammation has given rise 
to occlusion of the hepatic or common duct, intense jaundice. 

The treatment of inflammation of the mucous membrane of the 
biliary apparatus must be in the main antiphlogistic — our object 
being to subdue the local inflammation, to remove the unhealthy 
secretion, and restore the health of the organ. The inflammation, 
however, is one affecting a mucous surface, and therefore depletion 
must be used with caution. With this end, leeches or cupping to 
the margin of the ribs have been recommended ; but when, as is 
most commonly the case, there is jaundice (and in fact our diagnosis 
cannot be complete without it), the latter should be employed; 
indeed it may well be questioned whether it is ever justifiable to 
use leeches when there is jaundice, owing to the great difficulty in 
stopping the haemorrhage which under such circumstances often 
flows from the leech-bites, and has been known in some instances to 
prove fatal. For promoting the expulsion of the accumulated 
mucus, we do not perhaps possess any remedies which can be strictly 
compared to expectorants as applied to the bronchial membrane ; but 
certainly there is no more effectual method of promoting the flow of 
its secretion from the liver, than by exciting the action of the part 
into which it should be poured ; for this purpose saline purgatives 
are well adapted, and there is no combination better than the sul- 
phate with the carbonate of magnesia ; when there is heat of skin, 
diaphoretics should be employed, and with them antimonials, if there 



JAUNDICE. 307 

be no sickness (F. 5). Mercury is a much-abused remedy in all 
biliary derangements ; and when there are any signs of pyrexia it 
should not be employed except so combined as to insure its purga- 
tive action ; though it may be remarked that its employment in this 
disease is not directly in opposition to all rational principles of thera- 
peutics, as it is when the substance of the organ is the seat of disease. 
The pills of blue pill and colocynth, may, however, be given with 
safety when the bowels do not respond to the saline aperients. 
When all inflammatory action is at an end, moderate doses of pil. 
hyclrarg. or hydr. cum cret. may be used at intervals, much on the 
same principle as we would employ stimulating expectorants in 
chronic bronchitis. Socla again, which is one of the constituents of 
the bile, and therefore likely to pass out of the system by the liver, 
is well fitted for such cases, since it is probable that it also corrects 
the character of the secretion in the ducts, by rendering it less viscid; 
an effect similar to that which is known to be produced by this and 
other alkalies in similar affections of the bronchial tubes. Taraxa- 
cum is another remedy which appears to modify the quality of the 
bile, and in affections of the biliary passages, which have assumed a 
chronic form, it is peculiarly applicable. It imry, under these cir- 
cumstances, be combined with the soda or liq. potassas. In some 
chronic cases, it seems also to exert an admirable cholasrogue influ- 
ence when combined wtth nitric acid * Hydrochlorate of ammonia 
also is a cholagogue, the importance of which is hardly sufficiently 
appreciated in this country : after the bowels have been freely re- 
lieved by saline and mercurial purgatives, it may be administered in 
doses of about ten grains (F. 49). 

We have already frequently alluded to jaundice as a symptom of 
various affections of the liver, whence it must be apparent that it is 
in reality nothing more than an effect, we might even say a symp- 
tom, which may arise from various causes ; yet, as it is often spoken 
of as a disease per se ) and in the present state of our knowledge, we 
are also sometimes compelled to recognise it as such, and as, although 
it may be a secondary lesion, yet it may give rise to subsequent 
ones, and those of no mean importance, it is expedient to give it a 
separate notice. 

Jaundice, then, is to be recognised by the yellow skin and eyes, 
white stools, and deep saffron-coloured urine which stains the linen. 
The diagnosis of the disease is, therefore, almost obvious at first 
sight, the question being as to its cause ; but even before pronounc- 
ing the disease to be jaundice, we must look carefully in the pati- 
ent's face, since some persons have a sallow complexion not unlike 
the hue of jaundice; and the tinge in some chlorotic females is nearly 
of the same cast, as is also that in the remarkable discoloration to 
which Dr. Addison has lately called the attention of the profession 

* (49) R. Ammonice Hydroch. gr. s. 

Pulv. Tragacanth. co. gr. x. 
Aq. Cinnam. 3 iss. 
Ft. Haust. ; to be taken three times a-day. 



308 JAUNDICE — ITS SYMPTOMS. 

in connection with the renal capsules. A careful examination of the 
conjunctivae, which are pearly in the latter affections, will soon 
remove all doubt. The stools again are not necessarily white in 
jaundice, as we shall presently have occasion to notice ; and there 
may be white mucous stools without jaundice. The urine is, how- 
ever, always dark, sometimes nearly resembling London porter, with 
a yellow margin, and giving a deep-green colour with hydrochloric 
acid. 

The jaundiced appearance then is produced by the presence of 
the bile in the serum of the blood, whence a portion of it, and at all 
events its colouring matter, is carried off by the kidneys, giving rise 
to the dark urine ; whilst the pale colour of the faeces arises from the 
bile not finding its way into the alimentary canal. 

There has long been a question as to the manner in which the bile 
finds its way into the circulation, and in this is involved a preliminary 
question, as to the orgin or formation of the bile itself. The earlier 
opinion was that the bile was formed in the liver, and when its. exit 
through the ducts was obstructed, it was reabsorbed into the system, 
and gave its characteristic colour to the tissues. The discovery, 
however, that the urine was not formed by the kidneys, but in the 
extreme circulation, led to the belief that the bile was so likewise. 
The cases are not however strictly analogous, since the bile must be 
regarded as not entirely excrementitious, like the urine, but also as a 
secretion having important uses to fulfil before it is finally expelled 
from the system. There can however be little doubt that ingredients 
which are noxious enter into its composition, and that these may, 
when the secreting organ is diseased, remain in it and produce in- 
jurious effects. 

We may thus have two classes of phenomena presenting them- 
selves in jaundice. First, those arising from the non-performance of 
the proper office of the bile; and secondly, those which may be pro- 
duced by its action, or that of some of its ingredients when not 
eliminated from the svstem. 

Amongst the first class of symptoms may be reckoned the colour 
of the skin and conjunctivae, the dark colour of the urine, and the 
absence of colour in the stools, the stools being rarely paler than 
natural; but besides these, and more important, there is impediment 
to the natural conversion of the food after it has passed from the 
stomach, and a liability to speedy decomposition and fermentation ; 
the consequences of which are that nutrition is checked, and the 
patient becomes emaciated and languid, and also that the stools, 
besides being pale, are offensive, sourish, and apparently in a state 
of fermentation. Of the latter class of phenomena are the stupor, 
delirium, coma, and other signs of cerebral derangement not uncom- 
monly observed in jaundice; and perhaps we may add the occasional 
excitement of serous inflammation. Now it is a fact which must be 
familiar to every practitioner, that in many, or rather in the greater 
number of cases of jaundice, we have the first class of symptoms 
without any of the latter and more alarming ones, unless it be torpor 
or apathy, not amounting to stupor, which often attends simple jaun- 



GALL-STONES. 309 

dice, though, it is not unlikely that this is to be accounted for by 
the impaired nutrition and consequent languid circulation through 
the brain. 

Another effect of jaundice in all its forms is the tendency to 
haemorrhage, not only from those organs which discharge their 
venous blood into the portal vein, but from all parts of the system, 
sometimes giving rise to purpura, and always rendering every solu- 
tion of continuity more than ordinarily dangerous. 

The above include the essential symptoms of jaundice, the others 
which frequently accompany it belong more properly to the lesion 
of which the jaundice itself is an effect or symptom. 

Jaundice, as we have seen, may be induced by mechanical venous 
congestion of the liver of the passive character, as well as in the more 
active congestion, arising probably from over-stimulation (p. 295). 
In the former case the jaundice probably first commences in the 
liver ; when the bile is re-absorbed into the circulation it shows itself 
mainly by the yellowness of the conjunctive, and by the colour of 
the urine, which is also at the same time loaded with urates and pur- 
purine. In the jaundice from the more active form of congestion, 
we have a greater tendency to the more formidable symptoms of 
suppressed secretion. Such cases are not common. The following is 
an illustrative one : — A young married woman, during the absence 
of her husband at sea, indulged too freely in the use of spirits ; her 
conjunctivae and complexion became yellow and her urine of a deep 
saffron; the pulse was not at first accelerated, but afterwards became 
very rapid and feeble ; her tongue was coated, with rather red edges : 
there was at first sickness. The stools were dark. Her countenance 
was dusky as well as turgid, and there was an appearance of venous 
congestion over the whole surface. There was no pain, though much 
tenderness, in the right hypochondrium, and the liver could be felt 
below the ribs. She was at first relieved by purgatives, but subse- 
quently became delirious, the delirium assuming more and more of a 
low muttering character ; and she ultimately sunk in a state between 
coma and exhaustion. Here then was evidently toxaemia arising 
from a suppression of the secretion, or from decomposition of the 
retained principles of the bile. It may be suggested that this case 
partook of the nature of the destruction of the hepatic cells to be 
presently noticed, but the enlargement of the liver is at variance 
with this opinion. 

Catarrhal inflammation of the ducts is probably the most frequent 
cause of simple jaundice : this jaundice may be of varying intensity, 
both as regards the colour of the skin and the urine, and the paleness 
of the stools. When there is thickened mucus obstructing the com- 
mon duct, the jaundice becomes complete, and the same must occur 
when the ducts become obstructed from thickening or adhesion. 

There is, again, another cause of jaundice from obstruction in the 
ducts, which deserves especial notice from the severity of the suffer- 
ing which ordinarily attends it, and that is gall-stone. Gall-stones 
are concretions in the ducts or gall-bladder, consisting commonly of 
cholesterine with colouring matter of bile. These concretions are 



310 JAUNDICE. 

sometimes solitary, sometimes in great numbers, and may form either 
in the gall-bladder or in the ducts ; they may be of various sizes, 
sometimes as large as a filbert : these concretions are often found in 
the gall-bladder, and it may be by their escape thence that they first 
make themselves felt either in the cystic or the common duct, though 
they may be present and cause obstruction in the hepatic duct or 
any of its branches. The symptoms attending passage of a gall-stone 
are — intense pain in the region of the liver, extending to the scapula. 
It is sometimes of a dull aching kind, though more frequently it is 
acute, and appears to be the most agonising that can be inflicted ; it 
comes on in paroxysms, and is attended with vomiting of sour matter, 
and sometimes hiccough, with a frequent catching inspiration. The 
intense pain, aided it may be by irritation so near the solar plexus, 
brings on a state of the greatest exhaustion, either reducing the pulse 
below the natural frequency, or else rendering it very quick and 
feeble. In a case which occurred to the author, the patient appeared 
to have died from the depressing effect of a large gall-stone in the 
common duct, since the symptoms had not been of an hour's dura- 
tion, and there was no jaundice, though the duct was completely 
obstructed. There are often rigors, sometimes recurring periodically. 
If the obstruction do not give way, the urine becomes high coloured, 
and in most cases the patient brightly jaundiced. This will not, of 
course, be always the case, since whilst the concretion is in the cystic 
duct there need be no jaundice, and if from its angular shape it only 
partially obstructs the common duct, the jaundice may be slight, 
or only transient, appearing and disappearing with great rapidity. 
Should the gall-stone not be expelled, the patient either dies from 
the depressing effect just noticed; or, owing to the effect of the con- 
tinued obstruction upon the tissue of the liver, the secreting cells 
become disintegrated, giving rise to a fatal form of jaundice to be 
presently noticed. 

The most satisfactory evidence of the cause of the jaundice is the 
detection of the calculus in the evacuations. If the fasces be mixed 
with water, it is probable that the gall-stone, which is specifically 
lighter, will rise to the surface. It is, as Dr. Watson observes, a 
great gratification to the patient to see that his enemy has been ex- 
pelled. There may, however, be more lurking behind. When the 
gall-stone has one or more flat polished faces, it has probably been 
in contact with several others in the gall-bladder. 

Besides the obstructions within the ducts, there may be causes of 
pressure from without, as from malignant disease in the neighbour- 
hood of Glisson's capsule, in the small lobes of the liver, in the 
pylorus, the head of the pancreas, or the duodenum. Under these 
circumstances the jaundice will commonly come on very gradually, 
and there will be emaciation, often enlarged and hardened glands in 
the axillae, groins, or elsewhere, or other signs of malignant disease. 
Malignant growths in the liver may produce jaundice by pressing 
upon the ducts, but it may as frequently happen that there is exten- 
sive disease of this kind in the liver without jaundice, the fact being 
that such disease is in the organ, not of it, and therefore unless the 



TREATMENT OF JAUNDICE. 311 

growth act mechanically the function of the organ is not interfered 
with. 

We have already alluded to disintegration of the secreting cells of 
the organ, and to this cause Dr. Budd has, with much apparent reason, 
referred a fatal form of jaundice which is occasionally met with, and 
sometimes appears almost epidemic, though Dr. Bright considers it 
as resulting from diffused inflammation of the liver. 

This formidable disease is not at its commencement unlike ordinary 
simple jaundice. The skin and conjunctivae are bright, the urine 
dark. Dr. Budd states that the stools are pale ; but this is at variance 
with the experience of the author, who in two cases which occurred 
in his own practice, found the evacuation dark brown, not indeed of 
a warm ginger-bread colour, but a dark dirty brown which might be 
compared to the mud in the streets of London. Indeed he would 
almost be inclined to regard this appearance as symptomatic but for 
the counter-statement of so careful an observer as Dr. Budd. Dr. 
Graves, on the other hand, who was the first specially to describe 
these cases, speaks of dark stools as an unfavourable sign. 

In the course of an attack of what appears to be ordinary jaundice, 
either considerable irritability or excessive drowsiness supervene, the 
stomach becomes irritable, and there is vomiting sometimes of bilous 
matter; after a short time violent delirium, with pain in the head, 
supervenes, which ultimately subsides into coma, in which the patient 
expires. In the course of this affection the pulse, which may have 
been in the first instance slow, becomes quick with the excitement, 
but again becomes slow towards the close. 

According to the author's observation, the characteristic signs are, 
in the course of an attack of jaundice, stupor or irritability, a diminu- 
tion in the deep colour of the urine, and a darkness in the stools, 
without any sign of amendment, delirium, and coma. 

Dr. Bright, who refers the change in the liver to inflammatory 
action, states that the surface of the liver appears variegated, of a light 
yellow and dark red or purple, in patches ; and certain portions pro- 
ject above the rest, which, when cut through, sometimes prove of a 
softer texture, and even undergoing a procees of change or disor- 
ganisation. It is remarkable that the liver is alwaj^s smaller than 
natural. Dr. Budd, who refers the affection to disintegration of the 
hepatic cells, states that it may result from long retention of the 
secreted bile from closure of the common duct; but adds that, 
"destruction of the hepatic cells may take place rapidly without 
any obstruction of the gall-ducts, and instead of being consequent on 
protracted jaundice, the impaired nutrition of the cells may be the 
cause of jaundice that proves rapidly fatal." The small size of the 
liver is certainly opposed to the notion of inflammation. 

It is not impossible that there may be several causes for this disin- 
tegration. In some instances it may be a primary lesion, and the 
fact of this alarming disease having been known to attack several 
members of a family in rapid succession, would suggest the idea of a 
miasmatic origin. In others, obstruction of the common duct is the 
cause, and we would suggest that the smaller duct may be closed by 



312 TREATMENT OF JAUNDICE. 

catarrhal inflammation, as in the case of capillary bronchitis, and 
may give rise to disorganisation, as when the common duct is closed. 

The treatment of jaundice must be regulated in great measure by 
our knowledge of its cause. Of that arising from congestion and 
catarrhal inflammation we have already spoken. In the case of gall- 
stones, we must endeavour to favour the passage of the calculus. 
For this purpose opiates should be combined with purgatives and 
antimonials, provided there be not much sickness. Thus, a grain of 
opium with a quarter of a grain of tartar-emetic may be given two or 
three times daily, and the draught of sulphate of magnesia with the 
carbonate in the interval. Warm baths and hot fomentations are 
valuable adjuvants. Many recommend mercury; but if it increase 
the secretion without removing the obstruction, it must damage the 
liver. 

In regard to the treatment of the dangerous form of jaundice from 
disorganisation of the liver, steady purgation, we believe, holds out 
the best hope. Dr. Budd recommends the annexed formula (F. 50).* 
Mercury is decidedly objectionable upon the grounds just stated. 
When the excitement is great cold may be applied to the scalp, and, 
if the heat is diminished, a blister may be placed upon the back of 
the neck. 

Jaundice sometimes appears to be the result of impeded functions 
of the liver, from a lesion of innervation, as in the instances, not 
uncommon, of simple jaundice coming on after anxiety or depression 
of mind. In these cases the stools are white, the urine dark, and the 
countenance slightly jaundiced, the pulse slow, the patient languid. 
For this the best treatment is at first the blue pill and colocynth, with 
saline aperients ; subsequently, change of air and scene, moderate 
exercise, and compound decoction of aloes, with taraxacum. 

In cases of torpid liver, or jaundice from chronic change, the nitro- 
muriatic bath (F. 51), f recommended by Mr. E. Martin, is useful. 

* (50) R. Mag. Sulph. 3 ss.— 3J. 
Mag. Carb. gs. xv. 
Sp. Ammon. Arom. 3 ss. 
Aq. Puroe, g x. 
F. Haust. ; to be taken three times a-day. 

f (51)R. Acidi Nitrici, Ibij. 

Acidi Hydrochloric}, ft> ij. 

Aquoe ferventis, conj. xl. Misce. 



DISEASES OF THE (ESOPHAGUS. 313 



XYI. 

DISEASES OF THE (ESOPHAGUS. 

Acute inflammation of the oesophagus rarely occurs except as the 
effect of chemical or mechanical irritation. The symptoms are, pain, 
with inability to swallow either solids or liquids, but especially the 
former, the attempt being attended with great suffering, and the 
matters immediately rejected. The most appropriate treatment for 
this inflammation is local depletion as near the situation of the 
affected part as it can be applied, and what is of more importance, 
rest of the inflamed structure ; this is obtained by almost total absti- 
nence, nothing being taken except a very little thin barley water, or 
milk and lime water. These last may be used in equal parts, of 
which mixture a tablespoonful may be administered about every two 
hours ; the abstinence itself will be a means of subduing the inflam- 
matory action, and where the irritation is very severe, the rest allows 
it opportunity to subside. When, however, the irritation and conse- 
quent inability to swallow continues so long as to endanger the life 
of the patient by inanition, enemata of beef-tea must be administered. 

After inflammation of the oesophagus, the part involved is liable, 
as in the case of the urethra, to contract, and thus obstruct the passage 
through the canal: under these circumstances surgical aid may be 
employed to pass bougies down the tube, by which, however, only 
temporary benefit is often obtained, and the patient ultimately dies of 
inanition. Here also life may be prolonged by the diligent use of 
nutritive enemata. 

When there is stricture of the oesophagus, the portion of the tube 
above it is apt to become dilated, from distension by its accumulated 
contents. But the same dilatation sometimes takes place without 
such stricture, (possibly as an effect of inflammation, as we shall 
observe in other parts of the canal,) and, what is somewhat remark- 
able, we have an effect similar to that which is produced by stricture, 
namely, difficulty in swallowing. 

Ulceration is sometimes the effect of the obstruction ; in which case 
the contents of the oesophagus may be extravasated into neighbour- 
ing parts. This ulceration may, though rarely, take place sponta- 
neously. In a case which occurred to the author, a gentleman of not 
very temperate habits, after taking a considerable quantity of wine, 
became sick, and soon after vomiting, or in the act, was seized with 
severe pain in the side, with symptoms of sudden effusion, either into 
the chest or upper part of the abdomen. He sunk rapidly, and died 
in about eighteen hours. Upon examination after death, a consider- 
able quantity of port wine was found in the right pleural cavity. In 
the pleura was a small rent near the vertebrae, and corresponding to 
it was a perforation in the oesophagus, produced apparently by a cir- 
cular ulcer, without any elevation of the edges, and resembling those 



314 OBSTKTJCTION OF THE (ESOPHAGUS. 

which, occasionally occur in the stomach, and which will be noticed 
hereafter. 

Obstruction of the oesophagus may also be produced by malignant 
disease in any part of its course ; this most often occurs about its ter- 
mination in the cardiac orifice of the stomach, in which case the pain, 
and rejection of the food, are as violent and as immediate after the 
attempt to swallow as when the stricture is high up in the tube. The 
same symptoms may also arise from the pressure of aneurismal or 
other tumors of neighbouring parts. 

The oesophagus, like every canal surrounded by muscular tissue, 
is liable to have the passage of its contents obstructed by irregular 
contraction of these fibres, causing the food, as soon as it has passed 
into the gullet, to stop, occasioning a sense of pain either between the 
shoulders or in the passage itself. The symptoms are, as Dr. Watson 
observes, "the same as those which result from permanent stricture 
of the gullet, except that they are not permanent. "When the stric- 
ture is organic and abiding, the symptoms occur during or after 
every meal. When it is simply spasmodic, they come and go capri- 
ciously." Spasmodic stricture may be independent of any disease of 
structure in any part of the body, but it is of some importance to 
be aware that it may also be symptomatic of very serious organic 
changes,* as, for instance, ulceration in the larynx or even at the 
cardiac orifice of the stomach. True spasmodic stricture most com- 
monly occurs in persons of a highly-irritable state of the system, as, 
for instance, in hysterical females, or persons reduced by haemor- 
rhages, or excessive discharges of any kind, and is best relieved by 
checking or removing the weakening cause, and administering iron 
or zinc. In hysterical subjects the same remedies are applicable, the 
iron being preferred when there is evidence of anaemia, the zinc in 
the more purely hysterical subjects, in whom anaemia is not neces- 
sarily present; the tincture of valerian may also be advantageously 
given at the same time with the mineral tonics, 

* Dr, Watson's Lectures oa the Practice of Physic. 



DISEASES OF THE STOMACH. 315 



XVII. 
DISEASES OF THE STOMACH. 

Acute gastritis, by which, is meant inflammation of the mucous 
membrane of the stomach, is a rare disease in adults, except as a con- 
sequence of some irritant or acrid poison ; though it is not uncom- 
monly met with in young children. The anatomical changes pro- 
duced by it are a vivid redness of the mucous membrane, from 
injection of the minute blood-vessels, eccymosis into the sub-mucous 
areolar tissue, with softening of the membrane, so that it may be 
readily peeled off; the mucous follicles are rendered prominent, and 
here and there there are minute ulcers ; sometimes portions of the 
organ are found thickened, probably from tumescence of the areolar 
tissue, at other times the parieties are much attenuated, though this 
is probably a post-mortem effect of the gastric juice. It should be 
remembered, however, that the degree of injection of the minute 
vessels of the mucous membrane of the stomach,- is a very fallacious 
sign of inflammation having existed before death ; since not only will 
these vessels become injected from mechanical causes at or soon after 
it, but also their mucous surface, in which there has been unques- 
tionably much irritation during life, becomes pale after death. 

The characteristic symptoms of this disease are great irritability 
of the stomach, with pain, and extreme tenderness in the region of 
that organ ; the pain as well as sickness being excited by taking any- 
thing but the blandest liquids, and sometimes even by these. This 
pain extends round the hypochondria, and is particularly com- 
plained of between the shoulder-blades; there is urgent thirst, the 
tongue is white and furred, or brownish, and rather dry towards the 
centre ; it is almost always red at the tip and edges. The pulse is 
small, soft, and frequent, and there is excessive prostration. The 
skin is generally hot, the bowels confined, and the urine scanty and 
high-coloured. As, however, we have observed, it is in children 
that we are most frequently to expect this disease, and here we often 
find some spasmodic affection associated with it, generally a chronic 
spasm of the flexors of the fore-arm, wrist, and fingers on one or 
both sides, often a similar affection of the lower extremity. The 
subsequent progress of acute gastritis, if not relieved, coincides with 
what might be anticipated from the combined effect of irritation near 
the solar plexus, and continued inanition ; the pulse becomes more 
and more feeble, the eyes sunk and hollow, there is wandering 
delirium, or stupor, pallor of the countenance, with cold, shrunken 
extremities, and the patient dies of gradual syncope. 

The causes of the disease are very obscure : as before stated, it is 
rare in adults, unless induced by irritant poisoning, though it may 
be excited by the irritation of indigestible food in a system rendered 
susceptible of such irritation by protracted mental anxiety. In 



316 ACUTE GASTRITIS. 

children, gastritis may be set up by the irritation produced by 
teething, and probably, also, by improper articles of diet, allowed 
through carelessness or ignorance, and possibly by substances 
actually poisonous, taken in the same way, and by swallowing hot 
liquids. It may also arise from the retrocession of gout, erysipelas, 
or rheumatism, but more especially the former. Gastritis may also 
occur in connection with the exanthemata, and continued fever; 
though these cases are more rare and less violent than they are com- 
monly described. The ordinary causes of inflammation, such as 
exposure to cold or damp, may excite inflammation of this as of 
other mucous surfaces. Symptoms resembling gastritis may arise 
from disease obstructing the circulation through the right side of the 
heart, though they are rather the effect of mechanical congestion 
than of acute inflammation. Yiolent sickness may arise from inflam- 
mation or irritation of the kidneys, though in the latter case the 
injection of the mucous membrane of the stomach, which may be 
found after death, occurs rather as the effect than the cause of the 
vomiting; and the same remarks apply to sickness from intestinal 
obstruction. 

The diagnosis of acute gastritis is of considerable importance, from 
the fact of its being most commonly induced by irritant poisoning ; 
and therefore, where the symptoms just pointed out are present, a 
most careful investigation must be instituted, as well by chemical 
examination of the contents of the stomach, as by the search for 
other kinds of evidence bearing upon this point. For information 
upon this head we would refer the reader to the works of Dr. A. 
Taylor, and other medical jurists. Care also must be taken to ascer- 
tain that there is no hernia or other intestinal obstruction, and, which 
is perhaps more difficult, that the disease is not inflammation of the 
peritoneal coat of the stomach: from this it may be distinguished by 
the redder tongue, by the tenderness being less intense and less 
diffused, and by the pulse being softer. From nephritis, or the irri- 
tation of a calculus in the kidney, gastritis may generally he distin- 
guished by the absence of the pain described as belonging to the 
former, as well as by the burning pain in the epigastrium, and 
between the shoulders; examination of the urine will also assist the 
diagnosis, though it must be remembered that that secretion may be 
extremely scanty in both cases. The seat and character of the pain, 
even when there is no jaundice, will prevent the passage of gall- 
stones for being mistaken for gastritis, not to mention the greater 
frequency of the former affection. The prognosis of gastritis is 
always doubtful. When it arises from irritant poisoning, the degree 
of danger must depend much upon the nature and amount of the 
poison swallowed ; and even when it has arisen without such a cause, 
there is much danger from the depression produced directly by 
inflammation in this region, as well as by protracted inability to 
retain any nourishment. Continued sickness, failing pulse, cold 
extremities, and collapsed features are unfavourable symptoms. On 
the other hand, ability even to take the least nourishment, warmth 
in the extremities, and continued steadiness of the pulse may be 



TREATMENT. 317 

regarded as favourable. The more frequent disease of infantile gas- 
tritis is also dangerous, though in such subjects the prognosis is per- 
haps more hopeful than in adults. 

The treatment of gastritis is to be conducted mainly upon the 
principle of obviating the least excitement of the inflamed organ. 
Scarcely any medicines can be tolerated; and the practice too fre- 
quently adopted of administering repeated doses of calomel, is 
more likely to aggravate than relieve the symptoms. [In children, 
minute doses of calomel — from an eighth to a twelfth of a grain — 
repeated at short intervals, will be found the very best means in 
many cases to allay the excessive irritability of the stomach.] When 
the tenderness is great, and the prostration not excessive, a few 
leeches may be applied to the region of the stomach ; and sinapisms 
applied in the same situation are at all times admissible, and gene- 
rally beneficial. Equal parts of milk and lime-water, to the amount 
of about half a tablespoonful of the two combined, may be adminis- 
tered about every hour, though, should even this excite sickness, it 
must not be persisted in; in which case the lime-water alone may be 
tried. Impatience as regards the action of the bowels is to be depre- 
cated, though, should they not act for several days, a simple injection 
of gruel and salt may be administered; the patient may also be sup- 
ported by injections of beef-tea, administered twice or thrice in 
twenty -four hours. A similar plan of treatment may be pursued 
with children, and if it can be retained, a little hydrocyanic acid, 
with two or three grains of bicarbonate of soda with mucilage. 

Though acute inflammation of the stomach is very rare, we cannot 
but expect that the lining membrane of that organ, which is exposed 
to so many sources of irritation, both mechanical and chemical, 
should become the subject of chronic or of subacute inflammation. 
This inflammation, when long continued, produces thickening of the 
coats of the organ, and sometimes ulceration. In many cases the 
mucous membrane is roughened, thickened, and slate-coloured ; this 
latter appearance proceeding, probably, from the gastric juice dis- 
colouring the blood detained in the smaller vessels. Sometimes, with 
apparently increased vascularity, the surface of the membrane is 
thickened, and covered with a tenacious mucus ; at others, especially 
in hysterical females, in whom the symptoms often assume a charac- 
ter seemingly more acute, this mucus is bloody ; these appearances 
are most remarkable about the large curvature. When ulceration 
occurs, the ulcers may be of every variety of size ; in some instances 
they are less in circumference than a pea. with smooth and but 
slightly elevated edges ; sometimes, though this is not so common, 
there may be one large ulcer, with irregular, or thickened edges. 
These ulcers are often about the small curvature, sometimes perfora- 
ting the whole of the coats, and producing fatal peritonitis ; at others, 
they may be seen to have been prevented by adhesion to neighbour- 
ing viscera; sometimes the extra vasated contents of the stomach 
have been found enclosed in a sac composed of the walls of adjacent 
viscera and false membrane, so that life has continued a considerable 
time after the escape of the contents of the stomach. 



318 CHRONIC GASTRITIS. 

Caution is requisite in deciding upon the appearances of the inner 
surface of the stomach after death, as it is particularly liable to 
undergo changes in vascularity, from position, and, what is more 
deceptive still, changes in consistency, from the action of the gastric 
juice : these latter may even go to the extent of inducing solutions of 
continuity, that may by careless observers be mistaken for ulcera- 
tion; and as these solutions of continuity occur most readily in 
those who die rapidly, and after little previous disease, they have 
given rise to the question of irritant poisoning. A specimen was 
once brought to the author for his opinion as to whether the death 
of a child had been caused by poison ; the reasons for the suspicion 
being, that the child had been attacked with sickness, tenesmus, 
without any evacuation from the bowels, except a little blood, col- 
lapse, and death in a few hours ; and that after death a large ragged 
perforation, surrounded by softening, was found in the large curva- 
ture ; and further, that a portion of the intestines was in a state 
of intense inflammation. Upon being asked his opinion, the 
author immediately inquired if the part so said to be affected was 
not near the ileo-colic valve, and upon further examination it turned 
out that there was an intus-susception in this situation, and that the 
affection of the stomach was a post-mortem solution by the gastric 
fluid. 

The symptoms of ordinary chronic gastritis are, pain in the epi- 
gastrium and between the shoulder-blades, increased by pressure at 
the scrobiculus cordis, and by taking food into the stomach ; this 
latter feeling continuing for some time afterwards, or else not com- 
mencing till sometime has elapsed, being 'referrable, in fact, to the 
process of digestion then going on. There is also in most cases 
nausea, vomiting of mucus or of the ingesta, languor and restless- 
ness, the bowels are irregular; the evacuations sometimes pale and at 
others dark ; the tongue is generally coated with a drab-coloured 
fur, and red at the tip and edges ; or it may be red throughout, or 
glazed and chapped ; the pulse often quickened and sharp, the urine 
frequently scanty and high-coloured. 

There is, however, a great want of uniformity in the symptoms of 
chronic gastritis, the pain being in some cases wanting, there being 
only a feeling of acidity in the region of the stomach, the vomiting 
too is often absent, especially at the outset ; indeed, this symptom 
depends much upon the seat of the irritation, being more urgent the 
nearer the latter is to the pylorus : and it would seem that the seve- 
rity of the symptoms depends rather upon the extent than the depth 
of the irritation, since many cases have gone on to a fatal termination 
by a perforating ulcer, with scarcely any signs during life, the most 
common in such cases being a sense of heat and burning at the epi- 
gastrium, and between the shoulders. 

Chronic gastritis may terminate by resolution, and the patient may 
very gradually recover his appetite, powers of digestion, and general 
health ; in less favourable cases the disease may pass on to the still 
more chronic form of dyspepsia. In still more unfavourable cases, 
even of ulceration, there is reason for believing that the ulcers occa- 



TREATMENT. 319 

sionally heal, but at other times they perforate the whole of the coats 
of the orgaus, causing death from peritonitis. Sometimes, before the 
perforation takes place, adhesion is established to a neighbouring 
viscus : but the ulceration rarely stops there ; if the viscus be a 
hollow one, the ulceration goes on till it penetrates its walls ; and 
thus an opening may be made, for instance, from the stomach into 
the colon. The adhesion may, however, be to a solid viscus, as, for 
instance, the liver, spleen or pancreas ; in which case there is great 
danger that, the ulceration proceeding, some considerable vessel, or 
a large number of smaller ones being laid open, fatal haemorrhage 
will ensue ; or the same thing may happen from the ulceration open- 
ing an artery in the stomach itself. When the contents of the 
stomach escape into the general peritoneal cavity, death usually takes 
place at the end of between twenty-four and forty-eight hours. 

The causes of chronic gastritis are, a preceding attack of acute 
gastritis from any chemical or mechanical irritant, the habitual or 
frequent use of stimulating articles of diet or medicines, excessive 
indulgence in the pleasures of the table. Blows upon the region of 
the stomach may produce it, as will also leaning forwards so as to 
press the epigastrium against any solid body, as is observed in clerks 
at the desk, and still more in curriers and leather-dressers. It may 
also be induced by whatever excites a congestion of the lining mem- 
brane of the stomach or determines a flow of blood there; sometimes, 
for instance, it is a troublesome complication of those forms of dis- 
ease of the heart or lungs which impede the circulation through the 
right side of the former. In young females, it may occur as a sequel 
of the hsematemesis which often attends uterine derangement, more 
particularly amenorrhoea, and this is, perhaps, of all others, the form 
of chronic gastritis which is most apt to lead to ulceration : and it is 
a fact to be borne in mind that young females are, more than others, 
liable to perforating ulcers of the stomach, often without any previ- 
ous sign of inflammation beyond a sense of heat or acidity in the 
stomach so slight as to have attracted but little attention. These 
ulcers are, hoy^ever, not confined to such subjects, as they have 
been several times met with in elderly men, with the same absence 
of previously well-marked symptoms. 

The treatment of chronic gastritis depends mainly upon the prin- 
ciple of removing as much as possible every source of irritation from 
the inflamed surface; the most obvious and most effectual mode of 
fulfilling this indication is the keeping the patient strictly to the 
blandest and most easily assimilated diet. For this purpose, milk, 
as an article of food, is most eligible for those persons whose stomachs 
are not readily offended by it, and there are few with whom it will 
not be found to agree when combined with lime-water, and when 
but little or no other food is taken except bread. When there is 
tenderness we must have resource to more active measures, in the 
way of local depletion and counter-irritation. With this view six or 
eight leeches may be applied to the scrobiculus cordis, and in a short 
time afterwards a blister. In those cases in which there is much 
congestion about the liver and spleen, and in which the stools are 



320 MALIGNANT DISEASE OF THE STOMACH. 

very dark, small doses of blue pill are very useful. This is best 
given in the accompanying form (F. 52),* and unless the bowels act 
freely, the draught of sulphate of magnesia with the carbonate should 
be given every morning. When the pain and tenderness have been 
subdued, and the tongue has become cleaner and the pulse more 
tranquil, resource may be had to gentle tonics ; amongst these is the 
infusion of columba, to which may be added fifteen grains of bicar- 
bonate of soda, and when the bowels are torpid, about half an ounce 
of infusion of rhubarb. Care will for a long time be required to 
avoid every source of irritation in the way of diet. When the 
patient has been used to stimulants, a little bitter ale may be allowed 
or light wine ; about a dessert-spoonful of brandy in three parts of a 
tumbler of water is often recommended : but care should be taken 
that the proportion of the former is not gradually increased. We 
should not neglect to remind our patients that attention to the state 
of the skin in the way of frequent ablutions and moderate friction, is 
as essential to a healthy condition of the gastric as of the other 
mucous membranes. 

In addition to the changes produced directly by inflammatory 
action, the stomach is one of the organs most prone to specific ma- 
lignant disease; that is to say, to cancer in its various forms. The 
anatomical distinctions of these belong more to the province of the 
morbid anatomist, since, as far as our present experience teaches, 
the difference in the species of malignant disease affects but little the 
difference in the symptoms or result of the disease ; though, as regards 
the symptoms, there is a very great difference according to the part 
of the organ affected. The most sensitive portions of the stomach 
are, as we might almost have anticipated, its two extremities or 
orifices. These ostia both for ingress and egress, are also guarded 
by sphincters, for the purpose not only of preventing regurgitation, 
but also of opposing the passage of matters which are unfit to be 
transmitted through them. They become, when organically diseased, 
sometimes mechanically closed, sometimes exceedingly irritable, and 
sometimes permanently open; and, when there is excessive irrita- 
bility or sensitiveness, the parts of the canal leading to them become 
excited to contraction, to prevent the approach of offending substances. 
Thus, when the cardiac orifice of the stomach is the seat of cancerous 
disease, we have, in the earlier stages, great pain in the act of swallowing, 
at first referred commonly to the region of the heart, or to the left 
hypochondrium, and (which is the case with nearly all painful sensa- 
tion connected with diseases of the stomach) to the space between the 
scapulas. In more advanced stages of the disease, and when there is 
considerable ulceration or excoriation, there is almost an inability to 
swallow, so much so that the patient often refers the seat of this 
obstruction to the throat. When the pylorous is the seat of the dis- 
ease, there is little or no uneasiness in the act of swallowing ; but 

* (52) R. Pil. Hydr. gr. iss. — iij. 
Ext. Conii, gr. xij. 
Ft. Pil. iij. ; one to be taken three times a-day. 



CAUSES AND TREATMENT. 321 

after some time, usually about half an hour, there is considerable 
pain, generally described as a feeling of great distension, followed by 
vomiting. When, on the other hand, the large curvature is the seat 
of carcinoma, we have, for a long time, scarce any symptoms refera- 
ble to the stomach, there being commonly no sickness or pain in 
taking food. 

From what has been said, it may be inferred that the diagnosis of 
carcinoma of the stomach is often very obscure. When we have 
great pain in the region of the cardiac orifice, connected with the act 
of swallowing, and subsiding after the food has apparently entered 
the stomach, we may, in the absence of any assignable cause, suspect 
malignant disease of that ostium, which suspicion will be confirmed 
if there is vomiting of mucus coloured with a coffee-ground looking 
substance ; and if added to this there be hardened glands in any part 
of the body. When again there is pain about half an hour after 
taking food, followed by sickness and vomiting of coffee-ground 
matter, with general emaciation, and pains between the scapulae, we 
may suspect similar disease of the pylorus ; and we ought carefully 
to examine the epigastric region, where, if the disease exist, we shall, 
sooner or later, detect a tumor occupying the situation of the pylorus; 
and we shall also often find enlarged and scirrhous glands in the 
groins or axillae. When the disease is in the large curvature of the 
stomach, there will, from the absence of symptoms, be still greater 
obscurity, the first sign being often a tumor in that situation, and we 
shall be driven to form our diagnosis mainly by a method of ex- 
clusion; that is to say, from the absence of the symptoms of disease 
of any other organ in that situation. 

There is another form of disease of the stomach which has been by 
many authors included amongst the malignant affections of that organ, 
namely, the so-called scirrhus of the pylorus ; this consists in thicken- 
ing of the mucous and areolar tissues, with hypertrophy of the mus- 
lar, occasioned probably with its being thrown into more continuous 
action by the irritability of the overlying membranes, and thus in- 
ducing an induration and thickening, which may be compared to 
permanent stricture of the urethra. The symptoms of this stricture 
of the pylorus differ little or nothing from those of malignant disease 
in the same situation. It differs, however, in this, that it is not gene- 
rally associated with malignant disease in other parts. Obstruction 
in this situation is often (though not constantly) attended by great 
enlargement of the stomach, with pain at an interval of from half an 
hour to two or three hours after taking food. This pain extends 
between the scapulae, and terminates with a copious vomiting of 
yeasty matter, generally containing vibriones and sarcinae. 

The causes of the true carcinomatous disease of the stomach are 
no doubt the various irritations which would, in ordinary subjects, 
produce chronic gastritis; but in those in whom there exists the 
constitutional liability to those heterologous formations, these causes 
excite them in this particular part. They are more likely, too, to 
occur in advanced life; that is to say, when the powers of healthy 
nutrition begin to decline; thus they most frequently occur after 

21 



322 HAMATE MB SIS. 

the ago of fifty in men, and after the cessation of menstruation in 
females. The stricture of the pylorns, on the other hand, though 
no doubt more common in elderly persons, is by no means confined 
to such subjects, but is sometimes met with in persons- between 
twenty and thirty. The general termination of these diseases is 
from inanition, owing to the stomach being unable either to receive 
or to retain nourishment; but in the truly carcinomatous affections, 
the fatal termination by asthenia is accelerated by the effect of the 
malignant infection upon the whole system. Malignant disease of 
the stomach sometimes terminates suddenly by perforation and con- 
sequent extravasation into the peritoneal cavity. In those cases of 
stricture of the pylorus, which are of very questionable malignancy, 
death is caused solely by inanition. 

The treatment of these diseases when detected can, at the best, be 
only palliative; much, however, may be done by obviating all causes 
of irritation, towards relieving the sufferings of the patient and pro- 
longing his life to the utmost. In the first place, the food which is 
taken should be very small in quantity, and of the quality least likely 
to be either chemically or mechanically irritating; and in the earlier 
cases, nearly the same dietetic rales must be observed as will be laid 
down when treating of dyspepsia. In the more advanced cases, much 
suffering will often be avoided, and the patient may obtain tolerable 
nourishment, by restricting him entirely to a diet of lime-water and 
milk, with a little stale bread, which should be softened in the liquid. 
The lime-water may be mixed with the milk, either in equal parts, 
or in the proportion of two parts of the latter to one of the former, 
and the mixture may be taken either warm or cold, as may be most 
grateful to the patient ; but it should never be used hot x that is to say 
warmer than 120° Fahrt. The patient should never take more than 
three ounces at a time, but otherwise there need be little restriction 
as to quantity beyond his own feelings: nearly a quart of milk is 
sometimes taken in this way in the course of twenty-four hours. 
When even this or any other bland nourishment causes much pain 
or sickness, we must endeavour still further to spare the stomach by 
helping the nutrition of the body by enemata of animal broths. As 
regards internal remedies we cannot do much. In the less advanced 
stages bismuth in small doses often relieves the pain and sickness 
(the solid form either of pill or powder is to be preferred) ; another 
remedy, which often allays the sickness, is the ext. of nux vomica, 
made into a pill, with ext. of conium (F. 53).* When the bowels do 
not act, which is often the case, we must not run the risk of offending 
the stomach by aperients taken by the mouth, unless it be the addition 
of about one-third of a grain of ext. of aloes to each pill, but relieve 
them by aperient enemata. 

Haemorrhage from the stomach is not an uncommon occurrence, and 
may arise from various causes. 

(1). It may proceed from ulceration, caused either by chronic gas- 

* (53) R. Ext. Nucis roraicse, gr. i. 
Ext. Conii, gr. xii. 
Ft. Pil. vj. ; one to be taken three times a-day. 



ITS DIAGNOSIS. 32 



Q 



tritis or malignant disease. In cases of ulceration the haemorrhage 
may proceed either from a number of minute vessels exposed by the 
ulceration, or from a large vessel either of the stomach or some other 
viscus to which it has become adherent; or from a considerable 
extent of the internal surface of the organ, which has become to such 
a degree congested that the capillaries have given way. This con- 
gestion is generally the effect of mechanical obstruction to the return 
of the bloocl through the portal vein arising from the disease in the 
heart, lungs, or liver. 

(2). It may arise from similar congestion, though perhaps of a 
more active character, arising from the suppression of other san- 
guineous discharges, as haemorrhoids or the catamenia: of the latter 

CD O > 

it is often vicarious. 

(3). Haemorrhage from the stomach may also occur from changes 
in the blood itself by the disintegration of the corpuscles, by which 
the haematosine is dissolved in the serum, and in this condition is 
susceptible of transudation without any rupture of the walls of the 
vessels. 

It is important to bear in mind the probable causes of gastric 
haemorrhage as a guide to diagnosis. The diseases, or ^diseased con- 
ditions which may be mistaken for it, are haemoptysis or haemorrhage 
from the lungs, and vomiting of blood which has been swallowed 
from any other source. Ordinary haemoptysis, when there is con- 
siderable cough, and the blood florid and not in very large quantities, 
and mixed as it generally is with the mucous expectoration from the 
lungs, cannot readily be mistaken for gastric haemorrhage ; but when 
the blood is in very large quantities, it is apt to be swallowed, and thus 
rendered black in the stomach, and afterwards vomited, in which case 
we shall really have haematemesis or vomiting of blood, but not gastric 
haemorrhage ; and on the other hand, when the haemorrhage from the 
stomach is abundant, it may produce irritation about the glottis, 
and some of it passing into the larynx will excite coughing. Haemop- 
tysis, however, is generally preceded by dyspnoea and cough, and 
frequently by pain referred to the sternum; whereas haematemesis is 
generally ushered in by weight and pain at the epigastrium, and as 
the haemorrhage into the stomach generally takes place some time 
before the rejection of the blood by vomiting, we have pallor and a 
tendency to fainting preceding ejection, which, though they may 
attend or follow haemoptysis, rarely precede it by any considerable 
interval. In haematemesis the blood is commonly expelled in a large 
quantity at once, after which the discharge ceases, for a time at least ; 
whereas, at the close of the most profuse haemoptysis even, blood 
almost always continues to be coughed up in small quantities for some 
time. Blood may also be swallowed from the nares or fauces, espe- 
cially during sleep, and being vomited afterwards, may simulate 
haematemesis; but a ©areful examination of the parts will generally 
detect the source of fallacy. 

An inquiry into the previous symptoms will also aid us, not only 
in forming our opinion as to whether the haemorrhage is really gas- 
tric, but also as to its character, if it be such. Thus the history of 



324 



H M M A T E M E 8 T S A N D MELJNA. 



previous chronic gastritis, or of the burning sensation in the epigastrium 
which has been stated to accompany ulceration of the stomach, may 
suggest the belief that the bleeding is from an ulcer. Of the causes 
which produce mechanical venous congestion of the mucous mem- 
brane of the stomach, some, such as disease of the heart, may produce 
also engorgement of the lungs and haemoptysis; but in such cases the 
dyspnoea is urgent, and we have the signs of pulmonic apoplexy, nor 
do we often have copious haemoptysis from this cause. Obstruction 
to the portal circulation from cirrhosis of the liver is a very common 
cause of haematemesis, which, when not very profuse, may be con- 
sidered as a salutary relief under such circumstances, and we may be 
guided in our diagnosis by the previous history and present symp- 
toms of that disease. The haematemesis may always be suspected to 
be vicarious of menstruation when it occurs in young females, without 
any other lesion, which may account for it, and may be pretty cer- 
tainly inferred to be so when we have a history of uterine irregularity. 
The prognosis of haematemesis must depend much upon its 'probable 
cause. AVhen we have reason to believe that it proceeds from ulcera- 
tion, the prognosis is unfavourable, and it is so in the highest degree 
if that ulceration be malignant. When the haemorrhage is from 
mechanical venous congestion, the prognosis will depend mainly 
upon the disease which produces that congestion ; and, amongst such 
diseases, if we believe the case before us to be one of cirrhosis, 
although there is the highest probability of an ultimate fatal ter- 
mination, yet with respect to the haematemesis, we may regard it in 
a great measure as conservative, and give a favourable opinion as 
to the more immediate consequences. Plaematemesis as vicarious of 
menstruation need occasion no immediate apprehension beyond that 
of the possibility of it arising from ulceration, or being likely to lead 
to it. 

Connected with gastric haemorrhage, and generally a consequence 
of it, is the passing of the copious, dark, pitchy stools, commonly 
known by the name of melaena, consisting of blood, partly digested, 
and changed by its passage through the intestines ; sometimes, but 
rarely, the blood which is poured out into the stomach is not vomited, 
and the whole of it makes its appearance in this form. Melaena may 
also arise from haemorrhage taking place into the small intestines, 
either from congestion near the stomach, and produced by nearly the 
same causes as gastric haemorrhage, or into the ileum, as a conse- 
quence of ulceration of that part of the canal. 

The treatment of intestinal haemorrhage must be regulated mainly 
by our own knowledge of its cause. When it is of an alarming and 
dangerous character from malignant disease, and even from simple 
ulceration, — and upon the latter point there must always be some 
uncertainty, — we may have recourse to powerful astringents, of which 
the gallic acid is perhaps the most to be relied upon (F. 5-i).* Tur- 



* (54) R. Acidi Gallici/gr. iv. — v. 
Ext. Gentian, gr. ii. — iv. 
Ft. Pil. i. vel. ij. ; to be taken 
every third or fourth h^ur. 



Or, it may be given in solution, thus— 
I£. Acid. GaFlici! gr. v. 



Acid Ace.ici di). g ss. 



Syr. Aur.int. 

Aq. Puree, 3 x M. For a dose. 



6 =* 



TREATMENT. 825 

pentine has also been much recommended ; it may be given in doses 
of from fifteen to twenty minims every three or four hours, or oftener. 
In cases of haemorrhage from congestion, the hasty use of astringents 
is not only useless, but mischievous; we must, in such cases, first 
endeavour to remove the accumulated blood from the intestines, and 
at the same time aid the attempt which nature is making to relieve 
the portal congestion ; for this purpose purgatives may be employed ; 
indeed, in cases of haematemesis and melaena of this character (and 
they include a "very large proportion, especially amongst the intem- 
perate), we can do nothing by any other means until the bowels have 
been well cleared out. For this purpose we may, in the first instance, 
give a moderate dose of colocynth and calomel, and aid its operation 
by a terbinthinate enema; and after these have operated freely, a 
steady action must be kept upon the bowels by sulphate of magnesia 
with sulphuric acid (F. 55),* to which may be added a little alum ; 
cold drinks should be used, and soft and light nourishment must be 
empkyyed, and taken cold. We must remember, also, in the majority 
of such cases, that we have to deal with those who have used stimu- 
lants largely; therefore, when there is much exhaustion, we must 
allow wine or brandy; port wine is generally to be preferred. The 
cases which occur in connection with suppressed menstruation will 
be best treated by aloetic purgatives and iron (F. 56), f or after the 
bowels have been relieved, the tinct. ferri. sesquichlor. may be 
employed in doses of about fifteen minims. 

The haemorrhage from the stomach arising from disorganisation of 
the blood corpuscles, commonly occurs in connection with purpura, 
and must be treated accordingly. 

As a consequence sometimes of chronic gastritis, but often to all 
appearance independently of it or of any structural disease of the 
stomach, we meet with the troublesome train of symptoms known by 
the term dyspepsia. Now, although digestion is a complicated process, 
it is in reality not so mysterious a one as used to be supposed before 
it was elucidated by the labours of organic chemists, amongst whom 
in this country we are especially indebted to Dr. Prout and Dr. Bence 
Jones. 

* (55) }£. Mag. Sulph ^ i. — ii. 
Acid. Sulph. dil. tt^ x. 
Aluminis, gr. v. 
Syrupi Papav. g ss. 
Infus. Rosae co. g xiss. 
Ft. Haust. ; to be taken every four hours. 

f (56) R. Ferri Sulphat. gr. iv. 

Extracti Aloes, gr. iv. — vj. 
Saponis mollis, gr. iv. 
01. Menth. pip. n^ j. 
Ft. Pil. iv. ; of which one is to he taken four times a-day. 



326 DYSPEPSIA. 



XVIII. 
DYSPEPSIA 

Dyspepsia is a somewhat vague term, used to express the multi- 
farious and often distressing symptoms produced by an imperfect 
performance of the functions of digestion. 

The symptoms of this affection are so variable and so uncertain in 
their combinations, that the more prominent ones appear each to 
require a separate notice. 

Anorexia, or loss of appetite, may arise from a variety of causes, 
the nature of which must be as obscure as is that of the appetite 
itself, which has given rise to so much speculation amongst physio- 
logists. But whatever may be the immediate cause of hunger, it no 
doubt arises primarily from a want in the system of those materials 
which are necessary to repair the waste, or rather consumption that 
attends every operation in the living body. These materials may be 
divided into two great classes — the nitrogenized substances, for the 
supply of the consumption of albumen and fi brine resulting from 
the waste of tissues, — and the non-nitrogenized, which supply the 
materials for the combustion of carbon by union with the oxygen, 
by which combustion the animal heat is maintained. When the 
aliments that have been taken into the stomach have been dissolved 
and distributed throughout the system, there will, before they are 
entirely consumed, arise the feeling of hunger, if the stomach be 
empty, and the organs of digestion healthy. We have used the 
termed " dissolved" advisedly, since, as Dr. Bence Jones has well 
remarked, there is no such thing as chemical transubstantiation in 
the process of digestion ; that is to say, the nitrogenized or albumi- 
nous substances cannot be supplied without an injection of such sub- 
stances ready made in our food : neither can the stomach from 
carbonic acid and water, which exist everywhere around us, so put 
together the carbon, oxygen, and hydrogen as to form fatty matters, 
starch, and sugar — the non-nitrogenized alimentary substances. All 
that the digestive apparatus has to do, in the animal, is to dissolve 
them, together with the requisite earthy and saline matters, and send 
them through the lacteals, the lungs, the heart, and the blood-vessels, 
to the different parts of the system. 

Now, as the non-nitrogenized substances are intended mainly for 
the supply of carbon and hydrogen to support the eremakausis by 
which carbonic acid and water are being continually formed and 
exhaled by the lungs ; it must follow that when this process is greatly 
impeded, — as when the pulmonary circulation is obstructed, for 
instance, by disease of the mitral valve, or old capillary bronchitis, 
or when there is general venous congestion from feeble circulation — 
we have loss of appetite. And the same thing occurs in respect to 
the nitrogenized substances when there is a disturbance of the capil- 



SYMPTOMS — NAUSEA — FL A T U L E N C E. 327 

lary circulation, and consequent suspension of the vital functions, in 
fevers. Whatever, therefore, materially embarrasses either the pul- 
monic or systemic circulation, will destroy the appetite. For similar 
reasons, if the different excretory organs, especially the skin and the 
kidneys, be disordered, the same result will ensue : or if there be 
not loss of appetite, there will be delayed solution and absorption, 
and consequently pain from distension, when the first stage of diges- 
tion has been completed. 

In addition to these causes of vitiated appetite, we may also have 
lesion of innervation. The nervous communication between the 
brain and the stomach, or, what is more common, the brain itself, 
may be so disordered in its action that it does not correctly indicate 
the impression which it should receive from these nerves : and there- 
fore, there may be loss of inclination for food, and even aversion to 
it, from slight cerebral disturbance ; and it is an old remark that 
mental emotion, as grief or anxiety, immediately destroy the appe- 
tite. On the other hand, irritation at the roots of the nerves com- 
municating with the stomach, will often excite a craving or a 
ravenous hunger, and this is not uncommon in chronic disease of the 
brain. Excessive appetite may also exist when the stomach is able 
to digest well, and the chyle is taken up by the lacteals, but its pro- 
gress arrested by disease of the mesenteric glands, pressure upon the 
thoracic duct or in the course of the lacteals. 

Nausea and vomiting are very common and very troublesome 
symptoms in dyspepsia. These may occur at various intervals after 
the taking of food, and sometimes there is a sudden vomiting or 
rejection of the food without any previous nausea ; in other cases, 
again, there is continual nausea without vomiting, and this may be 
almost incessant, even though little or no food be taken. Sometimes 
there is continual nausea and retching, mucous and afterwards yellow 
bile being expelled by the inverted action of the stomach and duode- 
num. This vomiting is generally connected with a morbid irritabil- 
ity, the cause of which is very obscure : setting aside structural 
disease of the organ itself, it sometimes arises from hyperemia of the 
stomach from obstructed circulation through the heart, lungs, or 
liver. It is also in some instances the effect of a lesion of innerva- 
tion produced by slight cerebral disturbance; and, in some cases, 
again, we are unable to assign any antecedent cause for this condi- 
tion, and are obliged to regard it as primary lesion. 

Flatulence with eructation, or belching, is another consequence, 
and a most unpleasant one, of impaired digestion ; in many instances 
it is produced by the evolution of gases generated by the fermenta- 
tion of the food in the stomach, which, by being detained there, 
undergoes much the same changes which a similar mass of organic 
matters would do if placed in any bag, and kept moist, at the same 
temperature. Sometimes, however, this gas appears to be secreted 
by the stomach itself, for some persons suffer from it when that 
organ is empty, and are particularly liable to be troubled by it when 
a meal is delayed beyond the accustomed hour. AY hen the eructa- 
tions are produced by the decomposition of the food in the stomach, 



328 DYSPEPSIA. 

they will often be most offensive, even to the patient himself, some- 
times suggesting to him the idea of rotten eggs or foul drains, from 
the amount of hydrosulphuric acid evolved. In this case too the gas 
often brings with it fluid, or a portion of the solid matters in the 
stomach, as though the patient were ruminating. These matters 
which are thus belched up are often intensely acid, partly so from 
the acetic acid generated by the fermentation, partly perhaps by the 
irritated stomach secreting more than a usual amount of hydrochloric 
acid. 

Pain, in or about the region of the stomach, is a common though 
not constant symptom of indigestion. A common form in which it 
often presents itself is that popularly known as cardialgia, or heart- 
burn. In other cases, again, there is a more severe and violent pain 
coming on in paroxysms, which has been termed by nosologists 
gastrodynia, and, popularly, cramp in the stomach. 

The heart-burn is a sense of heat in the region of the stomach, 
generally towards the left side, often attended with eructation of 
acid matter. W hen*Lt occurs, as it frequently does, soon after meals, 
it is probably the result of acid, either acetic or lactic, produced by 
fermentation ; but sometimes it occurs when the stomach is empty, 
and the uneasy feeling is often relieved by taking food ; this r in all 
probability, depends upon an excessive acrimony of the fluids of the 
stomach itself. 

Sometimes, again, there is pain in the stomach immediately after 
taking; food, which continues until it is relieved bv vomiting. This 
in the majority of cases arises from chronic inflammation of the 
stomach, or undue irritability about the pylorus or duodenum, gene- 
rally of a subacute inflammatory character. In some instances, how- 
ever, there is continued increasing uneasiness, until at last vomiting 
takes place without any apparent irritability, but rather from a loss 
of tone of the stomach combined with the arrest of the natural 
changes of the food, the ingesta consequently remaining nearly un- 
changed, except by fermentation, until expelled by the combined 
efforts of the diaphragm and abdominal muscles. These cases are 
most frequent in females. 

A very frequent complaint, but one which seems not to have been 
much noticed by authors, is of pain coming on about twenty minutes 
or half-an-hour after a meal ; the pain is of a dull aching character, 
often extending through between the scapulas, and accompanied with 
a very uneasy feeling of distension, and sometimes flatulent eructa- 
tion. The tongue in this case is generally clean, though it may be 
indented at the sides by the teeth ; the appetite is not generally 
much impaired, the patient sometimes saying that he could eat if he 
were not afraid of the subsequent pain. The uneasiness in this 
case appears to depend upon delay of the food in the stomach, owing 
perhaps to a want of the proper solvent ; and it may be also from a 
want of nervous power. 

In other instances the pain does not begin till two or three hours 
after a meal; but continues for several hours. Dr. Abercrombie was 
of opinion that the cause of this pain was excessive irritability or 



pyrosis. 329 

subacute inflammation of the duodenum. Dr. Watson, however, 
holds, and with apparent reason, that the seat of the pain cannot be 
so near the stomach as the duodenum ; since, in that case, it would 
commence earlier, and believes it to arise from excessive secretion of 
acid in the small intestines. 

Pain again attacks the region of the stomach, in some instances, in 
violent paroxysms, accompanied with great flatulent distension. This 
form of pain, to which the term gastrodynia has been applied, is most 
common in hysterical females, often shooting between the shoulders, 
and sometimes extending over the whole abdomen ; it may, however, 
occur in all subjects, especially those whose bowels are apt to be 
constipated. In such cases it is produced in all probability rather in 
the colon than the stomach. Sometimes again we have spasm of the 
stomach, as it is termed, perhaps correctly, in persons of a gouty 
diathesis ; this so-called spasm is no doubt in many instances nothing 
less than incipient gouty inflammation, which, if it be not arrested, 
may speedily prove fatal. 

Pyrosis, or water-brash, is another troublesome concomitant of dys- 
pepsia, though it is said sometimes to occur without any derange- 
ment of the digestive functions. It consists of pain and contraction 
across the scrobiculus cordis, generally reaching through between 
the shoulders, and increased by raising the body to a perfectly erect 
attitude. This pain generally comes on when the stomach is empty, 
and after it has lasted some time there is an eructation of a thin 
watery fluid, which is often brought up in very great quantities. 
There is generally much derangement of the digestion in pyrosis, 
which is perhaps no more than might be expected from the quantity 
of the fluid diluting the natural gastric juice, and rendering it no 
longer a fit solvent for the food. The cause of the pain is not so 
obvious, but it is possible that it may be produced by distension 
from hyperemia, which is eventually relieved by the exhalation, 
from the mucous membrane, of this excessive secretion. Sometimes 
the secretion takes place in great quantity, just as the patient is about 
to commence a meal. In one instance an elderly gentleman was 
unable to commence his dinner till he rejected a large quantity of 
this fluid. Pyrosis may be symptomatic of organic disease of the 
stomach ; it may also be produced by pressure from neighbouring 
viscera, as in a case mentioned by Dr. Watson, where it was caused 
by the pressure of an enormous liver ; and water-brash, with severe 
dyspeptic symptoms, is one of the forms of disorder to which the 
curriers, who in their work are exposed to great pressure on the 
epigastrium, are exceedingly liable. 

Constipation, or rather costiveness, is at once a frequent con- 
comitant, and cause of dyspepsia; in some instances, no doubt, the 
liver may be at fault here, and the diminished flow of bile into the 
duodenum may be one cause of diminished peristaltic action of the 
intestines, which may also delay the contents of the canal above, and 
thereby disturb the action of the stomach. 

Besides these disorders, directly referable to the digestive organs, 
there are others which more affect distant parts. There is almost 



330 DYSPEPSIA. 

alwa} r s, to a greater or less extent, a loss of vigour both of body and 
mind, the muscles wasting, and becoming flabby from defective power 
of repair, and the brain losing its wonted energy, from a want of its 
accustomed supply of healthy blood ; but, as is generally the case 
when the tonicity of the system is impaired, there is an excess of 
excitability, though the functions of the nervous matter may not be 
so steadily and uniformly performed. Accordingly, there is fre- 
quently irritability of temper, great restlessness, and no steadiness of 
purpose ; or there may be that lamentable condition approaching 
almost to insanity, commonly known as hypochondriasis, in which 
the patient is in a state of incessant despondency respecting either 
his health or his affairs ; or it may be about his family, or the safety 
and prosperity of his country; but whatever be the object of his 
interest, it is also that of his most unfounded apprehensions — the 
onetus ex causis non czquis of Cullen. The nerves of sensation are also 
easily excited, and we often meet with pains in the thorax, or across 
the epigastrium. Headache is also a common symptom, as are also 
vertigo and confusion of sight. The tongue is generally coated, the 
bowels irregular, and flatulence is commonly a troublesome symptom. 
The pulse is often irregular, and frequently there is palpitation. 
These symptoms, together with the pain in the left side of the chest, 
excite great apprehension of disease of the heart. 

As dyspepsia consists essentially of defective performance of the 
functions of the stomach and parts immediately connected with it, it 
may be induced by structural diseases of these parts, and therefore 
the diagnosis between such diseases and simple dyspepsia must de- 
pend upon the presence or absence of the signs of the structural 
changes alluded to. Besides this, it closely resembles subacute gas- 
tritis in many of its symptoms ; but from this it may be distinguished 
by the pain, when it occurs, not coming on immediately upon taking 
food, but after an interval of twenty minutes or more. 

The causes of dyspepsia are very various. A common one is 
anxiety, or, great mental occupation, with little exercise and seden- 
tary habits, especially if the latter be attended by confinement in 
close rooms or offices. Indulging too freely at table, — eating too 
quickly, — and resuming active occupation of body or mind too soon 
after a full meal, allowing too short as well as too long an interval to 
elapse between meals — an imperfect performance of the functions of 
the skin, for the connection between the mucous membranes and the 
skin, of which the latter is but a continuation, is so close, that the 
former cannot reasonably be expected to continue in healthy action 
unless the latter be so likewise — an injudicious selection of articles 
of diet, both as regards their chemical and physical properties. 

In the treatment of dyspepsia the first object must be to obviate, 
if possible, the circumstances or conditions which have induced the 
disturbance of the functions of digestion ; and secondarily to palliate 
or counteract the ill effects and inconveniences arising from this dis- 
turbance. 

Now, the first principle in the management of disease of all kinds 
is to give as much rest as possible to any irritable, inflamed, or feeble 



DIET. 331 

organ ; and this applies to the stomach as much, at least, as to any 
other. 

The first rule then must be to insure the stomach not having too 
much food put into it at a meal. Dr. Abercrombie well remarked 
that we are apt to err quite as much in the quantity as in the quality 
of our food, or even more. Another important rule is to give time 
for the stomach to rest after digesting a meal. As a general rule, 
from four to six hours should intervene between one meal and 
another. When a person in good health has taken a hearty though 
moderate meal, including animal food, he can well go on for six 
hours or more, and even though actively engaged, he will hardly be 
ready for another within that time. When, indeed, the food has 
been of a light simple kind, bread, or bread and milk, or bread and 
butter with tea, or coffee, the stomach will have sooner emptied itself, 
and be sooner ready for the reception of more food ; and, therefore, 
Mr. Abernethy's rule of six hours, which allowed from four to five 
for digestion, and one for rest of the stomach, was a very fair one 
for the interval after a full meal : but with feeble persons, and after 
a meal of soluble food, the stomach would be empty, and after a time 
exhaustion will succeed much within this period. For persons who 
take very light and very soluble food, four hours is perhaps a suf- 
ficient interval. Nothing, however, can be more obviously absurd, 
than putting one meal into the stomach before the former one can 
have been converted into chyme, and have passed the pylorus, and 
thereby requiring the stomach to supply gastric juice for substances 
in different stages of solution. For similar reasons a variety in the 
articles of food must be bad, and also, because the use of several 
dishes affords a series of fresh stimuli to the appetite and induces the 
taking too much. Persons who are politely said "to be fond of the 
pleasures of the table," are almost always dyspeptic. 

It is next to impossible to lay down particular directions for the 
diet of persons in health; still more so for those who are the subjects 
of dyspepsia, since some persons are made exceedingly ill by articles 
of food which are for the generality of people wholesome, and others 
can best use those which are to most persons the reverse. Thus one 
lady could never, without undergoing the greatest inconvenience, eat 
any of the rhomboideal fishes, and another of apparently very irrita- 
ble stomach could live comfortably upon salmon. 

When the dyspepsia is dependent upon chronic inflammation of 
the stomach, there can be no doubt that butcher's meat should be 
abstained from, and that the diet should consist of a little white meat, 
as chicken or white-fleshed fish, and farinaceous food ; and where the 
irritability is great, of the latter entirely, with the addition of milk, 
which, however, does not suit all stomachs. 

Of butcher's meat, mutton is the most readily digested, and fur- 
nishes perhaps the greatest amount of nourishment in the least bulk. 
Bread again, it should be remembered, is the true pabulum rita\ as it 
contains all the materials, both non-nitrogenised and nitrogenised, 
required for nutrition; but in an undissolved state, and therefore 
requiring the trituration of mastication and the addition of some 



332 DYSPEPSIA. 

solvent in the way of drink, so that bread is the normal solid nourish- 
ment. Milk, on the other hand, contains the same materials ready 
dissolved, so that it is the normal liquid nourishment, and is that 
provided by nature for infants, who take no additional liquid for a 
solvent. Bread, therefore, is the substance which of all others is best 
suited for weak digestive powers ; but if it remain too long in the 
stomach it is prone to fermentation, whereby acids are generated 
and gases evolved. Animal food, which should consist of well- 
roasted or boiled flesh, fowl, or fish, is perhaps as readily chymified 
as any ; but there certainly appears to be required a certain amount 
of activity in the powers of life, and free action of the excretory 
organs, especially the skin, that meat may be well digested, and 
which is only compatible with a considerable amount of exercise in 
the open air ; as otherwise the tongue becomes loaded, the breath 
offensive, the urine foul from urates, and if there be not headache or 
sickness, the appetite fails and offensive eructations take place; the 
mixed diet is, therefore, most suitable for the generality even of 
dyspeptic persons, provided there are not many ingredients in the 
mixture. Vegetables again, such as potatoes and green vegetables, 
are liable to acetic fermentation in the stomach, and thereby cause 
acidity and flatulence, when not taken in very great moderation by 
dyspeptic persons ; but when omitted altogether, a state kindred to 
purpura is induced, in which the stomach eventually suffers with 
other organs from the diseased state of the blood. It appears, then, 
that though a person could live better upon bread than upon any 
one single article of food, that a mixed diet is, in the general, to be 
preferred, provided that the mixture be not too complex. 

In all articles of diet the physical condition should be considered, 
and therefore those which are soft and in a state ready for solution 
are the most eligible for weak stomachs ; those, on the other hand, 
which are rendered hard by artificial processes, as preserved and 
pickled meats, ham, &c, are to be shunned. Meat is as well, or 
better, roasted than dressed in any other way, as boiling produces 
a hardness on the outside which may be irritating to dyspeptic 
stomachs, particularly when the affection is dependent upon subacute 
gastritis. 

As regards liquids, it is probable that most dyspeptic persons take 
too much of fermented drinks, and the majority of such should 
abstain as much as possible; though there are cases in which a 
moderate use of wine, beer, or spirits, acts as a wholesome stimulus 
to the feeble stomach. As Dr. Watson well remarks, it is impossible 
to lay down any specific rules upon this subject, but that liquid 
should be selected which causes the least heat and irritation. Where 
there is a tongue with red edges, most alcoholic drinks will have this 
effect, and then it is better to abstain altogether. 

Next to the excessive use of ardent spirits, there are few things in 
regard to which people make so free with their stomachs as in the 
matter of tea and coffee ; that they are most grateful nervine stimu- 
lants cannot be doubted, and also that they are of great service by 
obviating the use of more pernicious beverages, but the large quan- 



i 



TREATMENT. 333 

titles which some persons take must, by diluting the fluids of the 
stomach, impede the process of digestion, and certainly those who are 
liable to painful distension of the stomach after meals, have this, 
much aggravated by tea in any considerable quantity. The proper 
quantity of fluid to be taken can hardly be defined by any certain 
rule; but for most persons about three pints in the day are neces- 
sary, and more than that is injurious. As regards liquid, or dissolved 
nourishment, it is not best suited for most dyspeptic subjects: but on 
this point we must be guided mainly by experience in each indi- 
vidual case ; and some very irritable stomachs are offended by any 
solid food. "When this is the case, lime-water and milk in propor- 
tions varying from equal parts of each to two of the latter to one 
of the former, will often be found soothing, and at the same time 
nutritious. 

In the selection of medicines as well as of diatetic remedies we 
must be guided, in great measure, by the symptoms which are most 
prominent among those which we have already described. 

In the sickness of dyspepsia we find a great uncertainty in the 
effect of remedies. In many cases, carbonic acid, either in the form 
of effervescing draughts or soda-water, have a very marked effect; in 
others, the mineral acids, especially the sulphuric, in infusion of green 
mint. But in a still greater number of cases, the alkalies, as liquor 
potassas, or carbonate of soda, are more effectual, and the combina- 
tion of the latter, in a draught, with three or four minims of the 
dilute hydrocyanic acid of the pharmacopoeia. Creosote is a doubtful 
remedy, and is nauseous to swallow, and still more nauseous to vomit 
up again. A very efficacious remedy is strychnia (F. 57),* in doses 
of from a 32nd to a 24th part of a grain. Bismuth is often service- 
able in allaying sickness: to this remedy, however, we shall again 
revert. 

What is, however, of most importance, is a careful restriction of 
the quantity put into the stomach, and more particularly the avoid- 
ance of taking food too frequently. Where the irritability is great, a 
good plan is to limit the patient to a large coffee-cup of milk and 
lime-water about every three hours ; and when the irritability 
diminishes, to allow a small quantity of meat (roast mutton, or a 
chop,) in the middle of the day. The bowels should also be kept 
open by the aloetic pill. Dr. Watson relates a case of chronic 
vomiting successfully treated in this manner; arid a similar case in 
Guy's Hospital was as speedily relieved by a careful, though not so 
strict regulation of the diet, and the use of the aloetic pill thrice 
a-day, with the addition of a quarter of a grain of extract of mix 
vomica. The loss of appetite, when the tongue is foul, will first re- 
quire the clearance of the intestinal canal by a dose or two of rhubarb 
and blue pill, followed, if necessary, by a gentle aperient draught. 
If, however, the bowels are irritable, a combination of rhubarb Avith 

* (57) R. Strychnia), gr. £— &• 
Acid. Acet. dil. 3 ij. 
Aq. distillat 5 iv. Misce. 
Dose, a large spoonful every four hours. 



334 DYSPEPSIA. 

an opiate is preferable (F. 58);* after this, the diet should for a time 
be of the simplest and least irritating kind, and it is a great mistake 
to solicit it by highly-seasoned dishes ; on the contrary, we may more 
frequently starve persons to an appetite by a very sparing diet. Where 
there is simply defect of appetite, the bitter tonics, with the addition 
of the mineral acids; or, when the bowels are rather torpid, one of 
these bitters with compound decoction of aloes, may be administered, 
and, what is far better when attainable, a good walk or ride in the 
open country, and occasional relaxation of mind, with change of air 
and scene. 

Flatulence, again, is another symptom requiring careful diet, as it 
is often the consequence of errors in this respect, either as regards 
quantity or quality. When the flatulence is attended by the "rotten- 
egg" eructation, there is probably undigested animal matter in the 
stomach or duodenum, and whilst this occurs the diet should consist 
of light farinaceous substances. Flatulent eructations and disten- 
sions will, however, sometimes occur spontaneously, or when, in 
weak stomachs, the interval between meals has been unusually long. 
When this is the case, a, careful regulation of the times of taking food 
is necessary. This flatulence is often speedily removed by some aroma- 
tic water, as peppermint or dill, or a few grains of calcined magnesia, 
with about half a drachm of tincture of cardomums in water: that 
which follows meals will generally be best obviated by swallowing, 
about half an hour before each meal, a pill composed of two grains of 
extract of rhubarb, with four of nitrate of bismuth. 

The pain in the stomach which precedes meals, and is sometimes 
relieved by taking food, is often removed by a small quantity of cal- 
cined magnesia ; but that which immediately follows taking food is 
less tractable, as it commonly depends either upon subacute inflamma- 
tion of the mucous membrane or organic disease of the stomach, and 
must be combated by the means best adapted for those affections. 
Small doses of the nitrate of bismuth, either in pill or in combination 
with hydrocyanic acid, will, however, often palliate it, as will also the 
nitrate or oxide of silver, in doses of about one-third of a grain. 

The pain, again, which follows taking food after a short interval, 
and is often unattended by any other manifest gastric derangement, 
the tongue being generally clean, is best relieved by the nitrate of 
bismuth, taken about half an hour before meal times. It may be 
taken either in the form of pill with the extract of rhubarb, or sus- 
pended with mucilage in a draught, and a few minims of dilute 
hydrocyanic acid may be added. The pain, again, which follows 
taking food at a longer interval, will often be prevented, when it does 
not depend upon any organic cause, by taking a small quantit}^ of an 
alkali immediately after a meal (as recommended by Dr. Watson), 
and of these a fixed alkali, in the form of liquor potassae, or liq. calcis, 
is the most effective, perhaps, from its not causing the evolution of 

* (58) R. Pulv. Rhei, gr. xv. 

Pulv. Gretas co. cum Opio, gr. x. 
Aq. Menth. pip. 3 x. Misce. 
.For a dose. 



TREATMENT. 385 

any gases, and sometimes fixing any acid ones that may have been 
generated. The mineral tonics, as sulphate of iron and zinc, are also 
not unfrequently useful ; and here too, as in several other painful affec- 
tions in the abdomen, the bismuth will be found eminently useful. 
The paroxysms of pain which have been described under the term 
gastrodynia, are sometimes greatly relieved, or even prevented, by 
the action of a brisk purgative ; it is, no doubt, most effectual in those 
cases in which there is distention in the arch of the colon, and in all 
affections of this description we should make sure of the free evacua- 
tion of the bowels. In many cases, however, these pains appear to 
be purely neuralgic, and are very common in hysterical females. 
They are then often relieved by mustard poultices applied to the pit 
of the stomach, by the combination of asther and opium, provided the 
bowels have been satisfactorily emptied, and by prussic acid. 

Water brash is often a very troublesome complaint, and, in some 
constitutions the secretion of an enormous quantity of fluid has 
become such a habit of the mucous membrane of the stomach, that 
it is next to impossible to arrest it. Astringents combined with 
opium will, however, often check it, and amongst these, the pulv. 
kino comp. of the Pharmacopoeia is extolled by Dr. Watson. The 
mineral astringents, as bismuth, nitate or oxide of silver, and oxide 
of zinc, are also very serviceable, and still more so when combined 
with extract of nux vomica, or very minute doses of strychnia (F. 
59).* The opium will often have the effect at first of increasing the 
tendency to constipation which ordinarily exists, though, after a time, 
this effect of the drug will often cease. When, however, there is occa- 
sion for an aperient, the compound rhubarb pill may be employed, or 
equal parts of compound colocynth pill and soap. The same reme- 
dies will be found effective when costiveness is the prominent symp- 
tom of dyspepsia ; or a mild dinner-pill may be employed. 

* (59) 55;. Ext. Nucis Vomicae, gr. jss. 
Argenti Nitrat. gr. ij. 
Ext. Lupuli, gr. xii. 
Ft. Pil. vj. ; one to be taken three times a-clay. 

Or R. Bismuth Nitrat. g ss. 
Strychnine, gr. \, 
Ext. Papaveris, gr. xii. 
Ft. Pil. vj. ; one to be taken three times a-day. 



336 PEEITONITIS. 



XIX. 

PEKITOXITIS. 

Like all other serous membranes,' the peritoneum is liable to inflam- 
mation. This inflammation may be acute or chronic; it may also be 
idiopathic or secondary, common, specific, or tuberculous. Acute, 
primary, or idiopathic peritonitis is by no means so common a disease 
as it was formerly, or perhaps still is ordinarily believed to be; yet, 
as this may be regarded as the primary or typical form, a description 
of it is necessary with a view to the right understanding of the dis- 
ease under the different conditions in which we more commonly meet 
with it. 

Peritonitis, then, as its name imports, consists in inflammation of 
the serous membrane lining the parietes and investing the viscera of 
the abdomen. In its acute and simple form it presents the ordinary 
phases of inflammation of such a structure. At first, the membrane 
. is dryer than in health, and the minute vessels more injected; next 
there is effusion of liquor sanguinis, of the fibrinous or molecular 
form, according to the vital powers of the patient. When this lymph 
is of the fibrinous character, it is generally speedily deposited upon 
the surface of the peritoneum in thin layers or flakes, the serum 
becoming quickly reabsorbed; these layers of lymph generally 
increase by fresh depositions as long as the inflammation continues, 
attaining every variety of extent and thickness, and forming adhe- 
sions between the contiguous portions of the membrane; so as to 
connect the different viscera, or portions of viscera, with one another 
and with the walls of the abdomen. The next stage of inflammatory 
effusion then takes place, and the lymph becomes organised, and the 
adhesions cellular and permanent ; the lymph in the process of organi- 
sation evincing the same tendency to contraction as in other situa- 
tions. When, however, the disease occurs in subjects of less plastic 
power, or in whom there is a deficiency in the solid contents of the 
blood, the serous effusion greatly predominates ; and, whilst the layers 
of fibrine may be deposited upon the surface of the membrane, the 
cavity itself becomes distended by serum, constituting one form of 
ascites. In some cases, again, of still feebler power, and where the 
lymph has been in the first instance entirely molecular, it may degene- 
rate into pus. Such is a brief sketch of the anatomical changes pro- 
duced by acute inflammation of the peritoneum in its more active 
form; these changes, however, may assume every variety of extent 
and situation. Sometimes the omentum is the part of the membrane 
chiefly affected, and it becomes adherent either to the walls of the 
abdomen or the intestines; in some cases, by its subsequent contrac- 
tion, drawing them together and partially strangulating them. Some- 
times the intestines become adherent amongst themselves or to the 
other viscera of the abdomen, as the stomach, liver, spleen, bladder, 



ACUTE PERITONITIS — SYMPTOMS. 337 

ovaries, or uterus ; and it need hardly be remarked that the functions * 
of these organs may thereby be seriously impeded. As we have 
before observed that peritonitis is more commonly a secondary than 
a primary affection, it appears that, in the majority of cases, this dis- 
ease is to be regarded as a most important intermediate link in a 
series of morbid action, being a very grave consequence of antece- 
dent diseases, (those of the blood, amongst others,) and the antecedent 
or cause of others of no less importance. 

The invasion of acute peritonitis is, for the most part, sudden, from 
whatever cause it arises; though, under some circumstances, it is 
almost instantaneous. It is characterised chiefly by severe pain and 
tenderness of the abdomen. The pain being scarcely a more promi- 
nent feature than the tenderness; so great, indeed, is the latter, that 
the pressure of the bed-clothes is hardly endured. The legs are 
drawn up to remove the pressure arising from the tension of the 
abdominal muscles; the breathing is extremely hurried, and is also 
thoracic, as the descent of the diaphragm, by disturbing the abdomi- 
nal viscera, and causing a slight motion of one surface of the perito- 
neum upon the other, would aggravate the pain; and the suffering 
caused by coughing amounts at times to perfect agony. The pain, 
too, is often increased or induced by assuming the erect posture, or 
by turning from side to side. It is truly observed by Dr. Watson, 
that though in true peritonitis there is generally occasional remission 
of pain, the tenderness is constant. 

It would appear from this that the tenderness is the essential 
symptom, and that the pain is the effect of circumstances which 
excite this tenderness ; thus, as the intestines are at times nearly qui- 
escent, we have an explanation of the absence of pain; but as they 
are liable to be disturbed, and to have their peristaltic action excited 
by the passage of aliment, of flatus, or even of their own secretion, 
or of that of the organs whose ducts pass into them, we can account 
for the frequent, and apparently spontaneous accessions of pain. 
The varying states of distension of the urinary bladder must also 
produce exacerbations in the pubic region. 

The pain which attends all the movements of the abdominal viscera 
may be regarded as the laesa partis functio, which is almost a pathog- 
nomonic sign of the disease, since the essential function of the peri- 
toneum may be said to be the providing a smooth, well-lubricated 
surface, to insure the painless movement upon each other of the con- 
tents of the abdominal cavity, and which is frustrated by the effects 
of the inflammation. Again, in an inflammation of the membrane, 
which constitutes one of the coats of the greatest portion of the intes- 
tinal tube, we naturally look to the state of the bowels ; and here we 
find uncertain and opposite statements amongst different authors; — 
thus, Dr. Alison says that the bowels are obstinately costive; Dr. 
Abercrombie, that they are not generally affected either by constipa- 
tion or the contrary; and Dr. Addison, that they are generally cos- 
tive. The statement of the last-named physician will, in the main, 
prove to be the correct one. Inflammation of the peritoneum does 
not per se affect the functions of the alimentary canal; if. however, 

22 



338 PERITONITIS — PULSE — URXXE. 

tlie peritoneal coat of the intestine becomes implicated, there is no 
fresh excitement to action as in the case of inflammation of the 
mucous membrane, nor any diminution in the power of acting, as in 
the case of inflammation of the muscular coat; but there will be 
diminished action in order to allow of the natural reparative process; 
and, therefore, the bowels are generally costive, but not necessarily 
in the early stage of the acute disease obstinately constipated. 
When, however, the inflammation in this situation has lasted some 
time, then, as we have frequently occasion to remark, the muscular 
tissue underlying the inflamed membrane loses its contractility, and 
constipation ensues. The same must necessarily become the case 
when the muscular coat itself is involved. Sickness, which is not an 
uncommon symptom, is generally ascribed to inflammation of that 
part of the membrane which covers the stomach; but it may occur 
when the inflammation is in other parts of the peritoneum, owing 
most probably either to nervous irritation, or to the inflammation 
involving the small intestines, and thereby causing obstruction in 
that part of the alimentary canal. 

The pulse, another important sign in all inflammatory diseases, 
presents great differences in peritonitis : thus, Dr. Addison describes 
it as " frequent, sometimes contracted, but nevertheless hard and 
resisting to the finger ;" and this is about the most accurate general 
description that can be given of it ; but it varies very much under 
the different circumstances of the disease, and in accordance with the 
principles laid down in speaking of the pulse generally (p. 74 et seq.) 
Thus in the onset of peritonitis it is hard, and generally full ; there 
being intense inflammation, increasing at the same time the tonicity 
of the artery, and the force of the ventricular contraction ; but cir- 
cumstances may arise to obviate the latter condition ; thus there 
may be exhaustion and shock to the system produced by the agent 
which excited the inflammation, by the nearness of the part affected 
to the expansion of the solar plexus, or even by its rapid develop- 
ment — and, consequent!} 7 , the hardness only remaining, whilst the 
injecting force of the heart is feeble, the pulse may become small 
and hard, that is to say, wiry and even thready. The fulness and 
hardness of the pulse both belong only to the active stage and fibri- 
nous form, which are typical of inflammation of a serous membrane ; 
but when the effusion is molecular, and, still more, when it has 
degenerated into puriform fluid, the pulse likewise loses in some 
measure its characteristic peculiarities, and becomes softer, approach- 
ing more nearly to the pulse of mucous inflammation ; and in extreme 
cases of suppurative inflammation of the peritoneum it is rapid, very 
small, and compressible. 

The state of the urine is also important in all cases of peritonitis. 
When the inflammation is at its commencement, and of an active 
character, the urine is commonly scanty and high-coloured. Dr. 
Abercrombie states that when the peritoneal covering of the kidneys 
is involved, there is almost total suppression ; though there is some 
doubt as to whether this may not arise from the suppression, and 
peritonitis having a common cause, rather than from the suppression 



causes. 339 

being the effect of the inflammation. The character of the urine is ♦ 
important also, — as should it be albuminous, it would indicate that 
the peritonitis is probably the effect of renal disease ; and should it 
contain a large quantity of lithates, it would indicate the likelihood 
of acute inflammatory action, with probably some hepatic complica- 
tion ; and should it be in large quantities, and of light specific gra- 
vity, it should suggest the existence of some form of hysteria 
simulating peritonitis. 

A knowledge of the causes of peritonitis is essential to the diagno- 
sis and treatment of the disease in its various forms. It may occur 
as a primary affection from exposure to cold or .excessive fatigue ; 
but this is its most uncommon form, so much so, that when we meet 
with what appears to be a case of this kind, we must inquire most 
carefully into the probability of some other cause. It may also 
occur in its most violent and rapidly fatal, or sometimes in a circum- 
scribed and more insidious form, from, perforation of some portion 
of the alimentary canal ; this generally happens after there has been 
some evidence of disease likely to produce such perforation either in 
the stomach, the small, or the large intestines, though sometimes a 
chronic ulcer may suddenly open into the peritoneum without any 
previous symptoms whatever. 

When perforation of the stomach takes place, it may arise from 
organic disease often of a malignant character, as was the case with 
Napoleon Buonaparte : or it may occur after protracted symptoms of . 
dyspepsia: or it may take place without any previous symptoms 
whatever ; this is most common in young females, but it has been 
known to happen in both sexes, and in more advanced life. The 
peritonitis from this form of perforation is generally fatal in from 
twenty -four to forty- eight hours, as, from the suddenness with which 
it occurs, there is no time for the formation of adhesions to circum- 
scribe the extravasated contents of the stomach. When the perfora- 
tion supervenes upon protracted disease with dyspeptic symptoms, 
the consequent extravasation is commonly circumscribed, and thus 
the fatal consequences may be delayed : in one instance of an elderly 
man, who had been long suffering from apparently intractable dys- 
pepsia, with great pain and distension immediately after taking food, 
several perforating ulcers were found in the stomach after death ; 
but most of these opened into the portions of intestine between 
which and the stomach adhesion had been established before the 
perforation occurred. Thus one communicated in this way with the 
duodenum, and two with the transverse colon ; whilst one opened 
freely into a large sac or pouch, formed by thick fibrinous lymph 
effused upon the surfaces of the adjacent viscera. In another case, 
which occurred some years ago in Gary's Hospital, there were the 
pain and tenderness of circumscribed peritonitis in the left hypoehon- 
drium, in an elderly female, who had before been in the hospital for 
what appeared to be chronic gastritis ; but what was remarkable, 
symptoms of pleuritis speedily followed, and shortly after those of 
considerable pleuritic effusion, combined with which there were 
metallic tinkling and amphoric cough and voice, so distinctly marked 



340 PERITONITIS. 

as to lead those who were unacquainted with the previous history 
of the case to believe that a pneumo-thorax existed. Inspection 
after death showed a large perforating ulcer of the stomach at the 
curvature through which the contents passed freely into a large 
pouch of false membrane, spread out upon the neighbouring viscera, 
the roof of which was formed by the diaphragm, through which the 
inflammation had extended by contiguity to the"' left pleura, giving 
rise to serous effusion in that cavity ; the pouch before mentioned, 
being distended by flatus from the stomach, produced the amphoric 
sounds by the succussion caused by the movements of the diaphragm 
in breathing, coughing, or speaking ; affording a curious instance of 
the auscultatory phenomena, which may be produced in the abdo- 
men. 

Peritonitis may also arise from perforating ulcers in the duode- 
num, jejunum, or ileum : those in the duodenum perhaps associated 
with a tendency to similar diseases in the stomach ; thus in the first 
of the two cases just referred to there was communication by ulcera- 
tion between the portions of the duodenum which are adjacent to 
each other. Perforating ulcers are very rare in the jejunum, and 
when they do occur, are probably of a scrofulous character. They 
are more common in the ileum, in which, especially towards the 
lower part, they are very apt to occur in fever, more particularly in 
that form which is characterised by a tendency to bowel irritation, 
and to which some have wished to restrict the term typhoid fever. 
These perforations are produced by the ulceration of the aggregate 
or solitary glands, so common in that disease, and when they do take 
place, generally occur about the fourteenth day of the fever. The 
peritonitis, which is set up by the extravasation from perforating 
ulcers in fever, is almost always fatal in about twenty-four hours ; 
since, owing to the want of plastic power in such subjects, there is 
little chance of its being circumscribed by adhesions. Strumous 
ulceration may occur in any portion of the intestine, and give rise to 
extravasation, and the same thing may occur in phthisis and dysen- 
tery. The contents of the urinary bladder may also escape into the 
peritoneum, either from chronic disease of that organ, or from the 
effects of stricture, though the latter is rare ; and perforation of the 
full bladder by ulceration has also been known to take place, the 
contents of which may thus escape into the abdominal cavity, and 
give rise to peritonitis. 

There can be no doubt, also, that inflammation of the peritoneum, 
to a greater or less extent, may arise from that of the other lining 
of the intestines, independently of that form which has been described 
as being produced by ulceration and perforation. Thus acute inflam- 
mation of the mucous membrane may by mere continuity involve 
also the muscular and serous coats, and this is the more likely to 
happen when the former is excited by violent purgatives, such as 
some forms of quack medicines ; thus more than one case has been 
witnessed arising from the use of Morison's pills. 

Peritonitis is more common in females than in males ; and proba- 
bly the chief reason of this being so is the frequency of peritonitis 



CAUSES. 341 

arising from affections of the uterus and its appendages. It is very- 
likely to arise after delivery, from imprudent exposure ; and per- 
haps partial peritonitis, giving rise to adhesion between the uterus 
and adjacent viscera, is a very common consequence of parturition, 
and is evidenced by subsequent pains and impeded action of the 
bowels or bladder. There is also the more fatal disease, commonly 
known as puerperal peritonitis, which, however, is a specific disease, 
requiring a distinct notice. 

Disease or irritation of the ovaries is a cause of severe peritonitis 
more commonly than is generally known, or at least recognised by 
medical authors. In one instance a young married lady who had 
menstruated regularly, imprudently sat upon the grass at a pic-nic 
party about the time that catamenia might be expected to appear. 
A few days afterwards she was attacked with rigors, followed by 
severe pain in the left iliac fossa, where there was great tenderness ; 
the pain gradually extended upwards, and to the right over the 
whole of the abdomen. To these symptoms succeeded sickness, 
obstinate constipation, a small, hard pulse, with paroxysms of intense 
suffering ; in short, the patient was in a state resembling that of per- 
sons suffering from a foreign body in the appendix cssci, with the 
exception of the chief pain being referred to the left instead of the 
right side. Upon inspection after death there was found to be ex- 
tensive peritonitis, which appeared to have commenced from the 
serous coat of the left ovary, the ovary itself being large, generally 
hyperasmic, and in one part containing a cyst about the size of a pea ; 
but which was believed not to be an ovarian foetation, of which a 
suspicion was entertained before death. Another instance, which 
was not fatal, was that of a young woman, a patient in the clinical 
ward at Guy's Hospital, in whom the symptoms very closely re- 
sembled those of a foreign body in the appendix ; this occurred at 
the menstrual period, the catamenia being delayed. The disease 
yielded to the treatment most adapted to peritoneal inflammation in 
that situation ; and after the action of the bowels had been restored, 
the catamenia appeared. If it be true, and instances might be mul- 
tiplied to prove that it probably is true, that peritoneal inflammation 
is a possible and not very improbable consequence of ovarian irrita- 
tion, the fact is important, not only in a pathological, but also in a 
practical and prophylactic point of view. Peritonitis may also arise 
from blood disease, and this is one of its most frequent causes. Thus 
rheumatic or gouty inflammation of the peritoneum is a possible 
though not very probable occurrence. It may also arise from the 
presence of bile in the blood ; but amongst all its causes there is 
perhaps none more frequent than uraemia or retention of the urea in 
the blood, owing to disease of the kidneys. 

It may also arise from the presence in the system of various morbid 
poisons, as of the exanthemata ; and there can be little doubt that 
the scarlatinous poison may affect the peritoneum, independently of 
the kidney disease, which is one of its common effects; the same 
remark applies still more to erysipelas. There is, however, one 
special form of peritonitis, belonging no doubt to the class of blood 



342 PERITONITIS. 

diseases, which, is of special importance from its fatality, and from its 
sometimes prevailing, to all appearance, as an epidemic : this is the 
disease commonly known as puerperal peritonitis. The inflammation 
begins in the peritoneal coat of the uterus, and extends thence over 
a large portion of the membrane ; it generally commences a few days 
after parturition, but appears to be distinct from the simple or non- 
specific peritonitis, which not very unfrequently follows that event, 
there being greater prostration ; in fact, its symptoms from the first 
are of a typhoid character. It has just been stated that the disease is 
frequently epidemic, and what is of more importance to be remem- 
bered, it is highly contagious ; so much so, that it may be conveyed 
through the medium of a third person; and it is no uncommon thing 
for a medical man who has attended a patient so affected to com- 
municate it to the next woman whom he may deliver. The know- 
ledge of this fact, and it is one almost universally admitted, renders 
it incumbent upon every medical man who has attended any one 
instance of it (as Dr. "Watson pertinently insists), " to use the most 
diligent attention ; he should even wash his hands with some disin- 
fecting fluid — a weak solution of chlorine, for instance ; he should 
avoid going in the same dress to any other of his midwifery patients ; 
in short, he should take all those precautions, which, when the danger 
is understood, common sense will suggest, against his clothes or his 
body becoming a vehicle of contagion and death between one patient 
and another." 

"We might even go further than this, and affirm that it is the duty 
of a medical man, who has attended cases of this disease, and finds 
that it is spreading, to relinquish, for a time, his midwifery practice 
altogether. 

Another point of scarcely less practical import, is the known 
relation between the poison of this disease and that of erysipelas; 
this is so firmly believed by many eminent obstetricians, that they 
take every possible pains to avoid being brought in contact with 
persons affected with the latter disease, lest they should infect their 
midwifery patients with the former. The same may be said, though 
perhaps not with equal certainty, of scarlatina. 

When peritonitis terminates fatally, it generally does so by death 
from syncope, or failure of the heart's action; the pulse becomes 
smaller and smaller, though generally to the last rather wiry (p. 74). 
This sinking is almost always preceded by a cessation of the pain, 
which has been by many authors referred to gangrene, which, how- 
ever, rarely occurs, though when it does, there is the same subsidence 
of pain. 

The diagnosis of peritonitis consists pretty much in a method of 
exclusion, namely, in the presence of acute pain recurring generally 
in paroxysms with great tenderness, and thoracic respiration, without 
the evidence of inflammation of any other tissue. Unless these 
symptoms present themselves in an hysterical female, in whom the 
neuralgic pains, which closely simulate peritonitis, can only be dis- 
tinguished from that disease by a careful investigation of the pre- 
vious history and constitution of the patient — by the pulse wanting 



causes. 343 

hardness — and by pressure being sometimes well borne when the 
attention of the patient is diverted, as by engaging her in conversa- 
tion at the time of making the examination of the abdomen, we may 
infer that the disease is peritonitis. The peripheral pain and tender- 
ness excited by inflammation of the spinal chord will also closely 
simulate the symptoms of peritonitis, though upon careful examination 
they may generally be distinguished. When the inflammation has 
extended to the muscular coat of the intestines, or that affecting the 
peritoneal coat of these organs is of sufficient intensity to arrest their 
peristaltic action, the symptoms will closely simulate those of strangu- 
lated hernia ; and a careful investigation should be instituted into 
the probability of such a cause for them. Where there is much 
sickness there will be scanty urine, and a question might arise be- 
tween peritonitis and inflammation of the kidney; the state of the 
urine, the character of the pulse, and the sickness being, in the case 
of the kidneys, a more prominent symptom than the pain, or at all 
events than the tenderness, will greatly assist in the diagnosis. 

The prognosis of peritonitis, when we have ascertained its existence, 
is at all times doubtful, as it is essentially a dangerous disease, the 
vital powers often failing suddenly, and with but little previous 
warning. It is not, however, necessarily a fatal disease, as the inflam- 
mation may subside or yield to appropriate treatment at any period 
of its course, and even when it has proceeded so far as to establish 
adhesions, these are not necessarily dangerous, unless they cause 
obstruction to the passage of the contents of the hollow viscera. 

As the fatal termination of peritonitis is commonly by failure of 
the moving powers of the circulation, the prognosis must depend, in 
great measure, upon the vital powers of the patient ; though these 
we cannot often accurately estimate : it must also be much influenced 
by what we can ascertain of the cause of this disease. When we can 
discover no assignable previous lesion as the cause of the inflamma- 
tion, we must regard the peritonitis as, per se, though a very dangerous, 
yet by no means necessarily fatal disease. The degree of danger will 
depend upon the probable extent of surface involved, also upon the 
part which appears to be most affected: thus, inflammation of the 
peritoneum near the diaphragm is more likely to be attended with 
that rapid sinking which is one of the chief dangers in this disease. 
Increasing quickness with diminished volume of the pulse is always 
a dangerous symptom ; whilst an increasing volume, some approach 
to softness and elasticity, especially if the pulse, at the same time, 
become less frequent, is an almost certain sign of the subsidence of 
the inflammation. Sickness and diminished urine are unfavourable 
symptoms; and a moderate flow of urine, with gentle warm perspira- 
tion, favourable ; but a cold clammy sweat is fatal. 

When we have reason to believe that the peritonitis is set up by 
perforation of any hollow viscus and extravasation of its contents, 
the prognosis is, in the highest degree, unfavourable ; yet even here, 
when the patient has survived more than forty-eight hours, we may 
reasonably hope that the extravasation is being circumscribed by 
adhesions. 



344 PERITONITIS. 

Peritonitis arising from uterine or ovarian irritation or inflamma- 
tion, (provided it be not of a specific character, as in puerperal peri- 
tonitis,) is generally amenable to judicious treatment, though it may 
be fatal, as in the case already related. The peritonitis of blood 
diseases is dangerous pretty much in the proportion of those diseases 
themselves; that of gout and rheumatism being rare, though not 
without great danger when it does occur: that arising from uraemia, 
as in Bright's disease, is not often the cause of death ; indeed it is 
rare to find the peritoneum alone implicated, and this inflammation, 
when it does occur, which happens in a very great number of cases, 
though of an acute is not often of a very active character, the effusion 
being mainly serous ; it is rather to be regarded as a consequence of 
a very dangerous disease, and also as adding, in no inconsiderable 
degree, to the danger, rather than as, upon its own account, very 
formidable. 

Of the scarlatinous peritonitis not much is at present known, but 
as far as we do know, there is reason to believe it to be highly dan- 
gerous, often speedily fatal, if not at all times necessarily so ; and the 
same may perhaps be said of the erysipelatous peritonitis. 

The treatment of acute peritonitis, like the diagnosis and prognosis, 
must be guided by our estimate of the powers of the patient and our 
knowledge of its cause. When we can detect no primary lesion, or, 
in other words, when we believe the cause to be one of simple primary 
peritonitis, the first object of our treatment must be to reduce the 
inflammatory action, the second to keep at rest as much as possible 
the inflamed part, and the third to induce a moderate mercurial 
action. Where there is no such depression of the pulse as to lead to 
the apprehension of immediate sinking, blood may be drawn from the 
arm ; and if the operation be followed by any increase in the volume 
of the pulse it may be safely repeated in a few hours. If by these 
measures we have in any degree diminished the hardness of the 
pulse, it will be more prudent not to repeat the venesection, but to 
apply from twenty to thirty leeches over the surface of the abdomen. 
The next indication, though apparently of almost a negative cha- 
racter, is of the utmost importance, namely, to obviate all disturbing 
cause which might irritate the inflamed part. For fulfilling this 
indication one obvious method is to abstain from the use of purga- 
tives, and there can be no more mischievous practice than the ex- 
hibition of such drugs in acute peritonitis ; the chief reliance should 
be upon opium, which may be given in grain doses, repeated at 
intervals of about four hours. There need be no apprehension of 
the opium confining the bowels, as it is by no means desirable that 
they should act as long as active peritonitis exists ; and when the 
inflammation has in some measure subsided, the probability is that 
the opium will act as an aperient. It is also worthy of remark that 
the opium will to some extent counteract the tendency to exhaustion 
produced by the bleeding, and that the bleeding will render the 
patient more tolerant of the opium. With the opium mercury may 
be combined, but never in such doses as to affect the bowels. As a 
general rule a grain of calomel may be given with each grain of 



DIAGNOSIS AND PROGNOSIS. 345 . 

opium, or if there be reason to apprehend irritability of the bowels, 
two grains of hjdrarg. cum cret. may be used instead. It is also im- 
portant to keep the patient in the recumbent position, and he should 
not be allowed to get out of bed, or even to sit up for any purpose 
whatever. When the pain and tenderness are manifestly diminished, 
a blister may be applied, but this is only admissible after the more 
acute symptoms have subsided, not only upon the general principles 
already laid down, but because the superficial tenderness caused by 
the blister may interfere with our examination of the abdomen, and 
may mislead us as to the real seat of the pain. Upon the same prin- 
ciple that we avoid disturbing the intestines by purgatives, we should 
endeavour to keep the stomach as tranquil as possible ; we should 
therefore forbid large draughts of anything, and endeavour to support 
the patient by giving from time to time about two tablespoonfuls of 
barley-water, or, what is perhaps to be preferred, especially if there 
be any tendency to sickness, about the same quantity of milk and 
lime-water in equal parts. When there is sickness it will often be 
counteracted by the opium or calomel, but should this not succeed, 
about ten grains of calcined magnesia (Henry's is the best) with five 
minims of vinum opii in an ounce of water, may be given every four 
hours. The practice of administering effervescing draughts, and 
thereby suddenly distending the stomach by the rapid evolution of 
gas, is at best inconsistent. Sinapisms may also be applied under 
such circumstances to the scrobiculus cordis. 

The treatment of peritonitis from perforation of the stomach, or 
any other portion of the alimentary canal, is almost hopeless ; yet as 
inspections after death show us that the consequent extravasation 
may be circumscribed by adhesions, and the fatal extension of the 
disease thus prevented, we must endeavour by all means to favour 
such a process. The great principle of treatment, then, in such a 
case, is rest. The patient should not only be kept quiet, but as far 
as possible motionless. Small quantities of bland fluid, not exceed- 
ing half an ounce at a time, should be given as nutriment (the milk 
and lime-water, for instance), and opium should be administered ; one 
good effect will be that we shall be better able to maintain the quiet 
which is so indispensable. By acting upon these principles, a case 
of perforation of the stomach was actually saved under the care of 
Br. Hughes and Mr. Eay of Dulwich, though the patient subsequently 
died of a similar disease. 

The peritonitic symptoms which not uncommonly follow parturi- 
tion, independently of the specific form of the disease constituting 
puerperal peritonitis, will generally yield to strict observance of rest, 
the application of about twelve leeches, followed by warm fomenta- 
tions, or the application of a warm linseed poultice, care being taken 
that the leech-bites do not continue to bleed too long after the appli- 
cation of the latter. 

As the peritonitis consequent upon ovarian irritation or inflam- 
mation may occur in every variety of intensity, it will require a 
corresponding variety of treatment. As it will in many eases be 
next to impossible to distinguish with certainty between neuralgic 



346 PEKITONITIS. 

and inflammatory pains, a middle course must often be adopted. For 
this purpose rest and an unstimulating diet should be enjoined, and a 
pill of one of the accompanying forms administered about three times 
daily, (F. 60.)* When menstruation is impending, the latter is to be 
preferred, the drops (F. 61)f being given in the intervals. In more 
severe and decided cases, where the tenderness is great, the pulse 
sharp, and the bowels confined, the treatment must be the same as in 
simple peritonitis, care being taken, however, not to carry depletion 
so far, the use of the lancet being rarely admissible. The caution 
about purgatives is also as applicable here as in other cases. When the 
inflammation has susided the bowels will generally act spontaneously. 
The treatment of peritonitis arising from urasmia belongs perhaps 
mainly to that of disease which gives rise to it : that arising in Bright's 
disease being generally of subacute character, very active depletion 
will rarely be required, but a few leeches may be applied to the abdo- 
men. Mercury, as is well known, is a most dangerous remedy in 
Bright's disease, and should therefore be rarely used. When admin- 
istered it should be withdrawn upon the slightest indication of its 
specific effects, which must be most carefully looked for. Saline 
diaphoretics, as the liquor ammonias acet. or the citrate of potass 
(F. 62)^: are often beneficial; and if there be no sickness, antimony is 
the remedy upon which we may place the most reliance. This may 
be given either in the form of the antimonial opiate pill (F. 26) or of 
three grains of James's powder with the same quantity of hyoscyamus 
three times a-day ; the opium, however, must not be administered if 
the pupil be contracted, or if there be any of the symptoms of cere- 
bral affection, so common in uraemia. When these latter symptoms 
are absent, the pulv. ipecac, co. in doses of three or four grains, three 
times a-day, will often be of service. In the peritonitis which some- 
times occurs almost contemporaneously with the invasion of scarla- 
tina, which is to be known in most cases only by its fatal result, we 
can of course do but little, the chief indications being for the use of 
stimulants. When, however, as is sometimes the case with the peri- 
toneum as well as with other serous membranes, it becomes inflamed 

* (60) ]J. Est. Hyoscyam. gr. x. 
Hydr. cum Cret. gr. iv. 
Ft. Pil. iij. ; one to be taken three times a-day. 

Or, R. Est. Conii, gr. x. 

Hydr. cum Cret. gr. iv. 
Ft. Pil. iij. ; one to be taken three times a-day. 

f (61) R. Liq. Potassae, ^ii. 
Sp. JSth nit, 

Tinct. Hoscyam. aa £ iii. M. 
A small spoonful to be taken three times a-day in an ouuce of barley-water. 

% (62) R. Pot. Bicarb. £ i. 

Acidi Citrici, gr. xv. 
Sp. iEth. nit. 3 ss. 
Syrupi Aurant. g ss. 
Aq. distillat. 5 x. Misce. 
For a draught, to be repeated three times a-day. 



TREATMENT. 347 

towards the subsidence of the fever, independently of uraemia (the 
signs of which should, however, always be carefully looked for), it 
must be treated upon the ordinary principles, though we must not 
forget that the patient has passed through a depressing disease, the 
poison of which is scarcely eliminated from the system; depletion 
must not, therefore, in ordinary cases be attempted, unless the pulse 
have considerable volume as well as sharpness, and the tenderness 
be intense. Calomel, with Dover's powder, or the antimony and 
opium and saline diaphoretics, must therefore constitute the staple of 
the treatment, the effect of the opium upon the brain being carefully 
watched. The same rules of treatment apply to the erysipelatous 
peritonitis. 

The treatment of puerperal peritonitis belongs more appropriately 
to the obstetrician ; but it belongs also to the general physician to be 
aware of the principles upon which this treatment is to be conducted. 
The inflammation may be stated to be the effect of the localisation in 
the peritoneum of the influence of a specific morbid poison, in which 
respect it may be said to resemble the serous inflammations which 
occur in influenza. There is, however, a greater tolerance of bleed- 
ing in the latter than in the former disease, and in some epidemics 
this measure is well borne ; but as a general rule it must be resorted 
to with much caution ; and in estimating its expediency, we must be 
guided as well by the general epidemic character of the disease, — 
that is to say, by the tolerance of depletion evinced not only by other 
patients suffering from the same disease, but by the greater or less 
tolerance of similar measures evinced in all diseases which may hap- 
pen to be prevailing at the time — as by the particular condition of 
each individual patient. When, for instance, fevers with a tendency 
to prostration, especially exanthems, such as scarlatina or erysipelas, 
quickly assuming a typhoid character, are prevailing, the lancet 
should be almost entirely laid aside, and even leeches used with the 
greatest caution. As regards the indication to be drawn from the 
patient herself, we must look mainly to the pulse : if in the onset of 
the disease the pulse is hard without being very small, that is to say, 
if the heart evince some power, and at the same time the inflamma- 
tory contractility of the pulse is well marked, blood may be drawn 
if there are none of the contra-indications from without which have 
just been alluded to. Next, if next, to bleeding in efficiency, and far 
beyond it in extent of applicability, is opium, which appears not only 
to fulfil the indication of restraining the peristaltic action of the intes- 
tines, but also appears to have a direct effect upon the disease. In this, 
as in other forms of peritonitis, or perhaps even more so, purgatives 
should be carefully avoided ; it has happened that the withdrawal of 
the opium, and administration of an aperient, has brought back the 
worst symptoms of the disease, when they had to all appearance 
subsided. 

Of chronic peritonitis Dr. Abercrombie truly observed, that this 
insidious affection is more common than persons not familiar with 
pathological investigations are generally aware of. It is a disease of 
the utmost danger, yet often extremely obscure in its symptoms and, 



348 CHEONIC PERITONITIS. 

can only be treated with any prospect of success "by the greatest 
attention to its earliest indications. 

This chronic, or more properly speaking, subacute inflammation of 
the peritoneum, may arise from a variety of causes: thus, in many 
cases, it is the effect of previous acute peritonitis, where there is 
organisation of lymph of different degrees of plasticity, accompanied 
by serum, which generally does not become absorbed ; in which case 
we have green and puriform matter, and, here and there, lymph 
agglutinating the contents of the peritoneal cavity. 

Another form of the disease, and that which includes, perhaps, the 
greatest number of instances, is associated with tubercle; and is the 
local affection by which the tuberculous diathesis most frequently 
manifests itself in more advanced childhood and early youth. The 
liability to the deposition of tubercles in the abdomen, and espe- 
cially in the peritoneum, may be said, as regards age, to follow the 
tendency to such deposits in the encephalon, and to precede that in 
the chest. In such cases, the disease consists in the deposition of 
various forms of tuberculous matter on the surface of the peritoneum ; 
in some instances there may be only the minute transparent miliary 
tubercle; in others again there may be associated with these, the 
flattened opaque white tubercle, lying apparently immediately under 
the surface of the membrane, without any inflammatory deposit 
upon it ; in others again, and those especially in which the cause of 
death is to be referred to the peritoneal disease, there is every variety 
of tuberculous and inflammatory deposits, agglutinating and knotting 
together some parts of the intestines into such an inextricable mass, 
that it is often next to impossible to unravel them. 

In another form of the disease, to which the term chronic is per- 
haps more particularly applicable, there is thickening, contraction, 
and opacity of the membrane, with little or no deposition of lymph, 
but a large effusion of serum, constituting one form of ascites. 

The symptoms of chronic peritonitis are, as has just been observed, 
in a great number of cases very obscure, it being often next to 
impossible to assign with any exactness the period of its first inva- 
sion. At first there is commonly more or less pain, which is either 
constant, or occurring in paroxysms: this pain is in some cases 
referred to a particular part, at others it extends over the whole of 
the abdomen; there is generally increase of the pain upon pressure, 
and also upon motion, or upon assuming the erect position, or there 
may be no pain, but merely a dread of pressure. The abdomen is 
generally rather tumid, and upon the whole resonant upon percussion, 
though there may be here and there points of dulness ; at times also 
what appears to be a solid mass may be detected in the abdomen 
by percussion and manipulation. In some cases, and these more 
advanced, the abdomen is flat, and the resonance defective : the abdo- 
minal muscles, especially the recti, are often strongly contracted, and 
give a feeling to the hand as of a nodulated mass beneath. In most 
cases there is vomiting at times in the course of the disease ; some- 
times, it may be, from intestinal obstruction, sometimes from inter- 
current acute peritonitis in the upper part of the abdomen, and, some- 



SYMPTOMS. 349 

times, in the tuberculous cases, from disease of the mesenteric glands, 
or enlargement of the glands in the neighborhood of the pylorus. 
The bowels are very irregular in their action, being in many cases 
irritable, though even where this is the case, they are liable to inter- 
vals of obstinate constipation ; sometimes the first appearance of the 
disease dates from an attack of the latter : the action of the bowels is 
almost always attended with pain. 

In addition to these symptoms, which are more directly referable 
to the abdominal disease, we find others which belong more to the 
state of the system upon which it depends, or to which it has given 
rise. In those cases which are the sequelae of acute peritonitis, there 
will not necessarily be any previous history of tuberculous or other 
cachexia, yet even here there will probably be some history of ante- 
cedent disorders which may have given rise to the first peritonitis; 
since, as we have pointed out, primary or idiopathic peritonitis is an 
uncommon disease, and therefore in these cases there will probably 
be elicited some circumstances which would excite the suspicion of 
some affection of the abdominal viscera, such as has been pointed out 
as likely to excite peritonitis, and in addition there will have been 
subsequent derangement of the health, with, in all cases, more or less 
general emaciation, with sinking of the countenance. These remarks 
are perhaps specially applicable in the case of females, in whom the 
peritonitis has been produced by ovarian or uterine disease. 

In the most numerous class of cases, those namely which are of a 
tuberculous character, the general symptoms will be those of the 
strumous diathesis, such as have been pointed out when treating of 
phthisis pulmonalis ; indeed, this form of peritonitis, with its frequent 
accompaniments of strumous affection of the mucous membrane and 
the mesenteric glands, constitutes a modification of phthisis abclomi- 
nalis. Instances of this disease generally present themselves in young 
persons between the ages of ten and twenty, and when in such sub- 
jects, we have pain and tenderness in the abdomen, with emaciation, 
and more especially if there be occasional flushings of heat, with a 
quick pulse, and tongue furred at the back and centre, with red 
edges; and if the bowels be irritable, with intervals of constipation, 
we may generally infer the presence of chronic peritonitis of a tuber- 
culous character. 

In the chronic peritonitis to which we have alluded as presenting 
more the appearance of ascites, there are no very characteristic 
general symptoms; there will be emaciation, and generally con- 
siderable anxiety of countenance; the pulse for the most part quick, 
the bowels torpid, the urine scanty, and often depositing urates. 

The progress of chronic peritonitis is liable to great variations; 
but in the majority of instances, unless it be early arrested, its ten- 
dency is to a fatal termination. In such cases, under favourable 
circumstances and judicious management, the bowels will become 
regular, and the evacuations healthy, often after the removal of large 
accumulations of solid matter, when the tenderness may disappear, 
and nutrition being restored, the patient regains flesh. But even 
under these circumstances, there is great liability to relapse, for since 



350 CHROMIC PERITONITIS. 

the previous accumulations had in all probability taken place through 
the contractility of portions of the intestines having been impaired 
by previous disease, there is a liability of its recurrence, and also a 
danger of fresh obstructions being established by the insidious pro- 
gress of chronic inflammatory action, and such cases require constant 
watching, and the greatest care for months after the disease has appa- 
rently subsided. If, on the other hand, the disease be not arrested, 
the tumescence and tenderness of the abdomen increase, with extreme 
pain, often referred to particular parts ; the action of the bowels becomes 
more irregular and attended with greater distress, sickness may become 
urgent, and the patient sinks, either exhausted by inability to retain 
nourishment, or worn out by the continual suffering; or, life may 
terminate more suddenly from perforation of the intestine consequent 
upon obstruction. 

The progress of that class of cases to describe which the term 
phthisis abdominalis has been applied, is very similar, as regards the 
constitutional symptoms, to that of phthisis pulmonalis, but even in 
these, we sometimes find the disease rather unexpectedly to recede, 
the abdomen losing its tumescence, the bowels recovering their 
healthy action, the patient regaining his health and strength : some- 
times too, even when the swelling has continued, and fluctuation has 
been distinctly felt, and hectic symptoms have been well marked, 
there has been an escape of pus through the ring of the external 
oblique muscle, or through the umbilicus, and the patient has 
eventually recovered. In by far the greater number of instances, 
however, when the disease has been well marked, emaciation has 
increased, and the patient has died of exhaustion, unless previously 
cut off by any of the casualties before mentioned. 

In the chronic peritonitis, which has been described as assuming 
the form of ascites, the fluid is rarely absorbed, and the continued 
pressure on the abdominal viscera commonly produces death from 
emaciation and exhaustion ; though even here it has sometimes hap- 
pened that the fluid has disappeared after a copious discharge of 
water, either by the bowels or the kidneys, or, in some cases, after 
an abundant flow of saliva. 

Since the symptoms of chronic peritonitis are so obscure and insi- 
dious, the diagnosis must, especially at the commencement, be diffi- 
cult ; and, although it may be true, as stated by Abercrombie, that 
when there is continued pain and tenderness in the abdomen, we 
may generally infer the existence of chronic peritonitis, there are 
diseases with which it may be confounded, amongst which may be 
reckoned, tabes mesenterica, worms, infantile remittent fever, and 
phthisis pulmonalis. As regards the first of these, it rarely happens 
that chronic peritonitis runs its course without more or less complica- 
tion of mesenteric disease, and although it may be doubted whether 
the latter is ever the direct cause of the former, there can be no 
doubt that peritonitis often supervenes upon it ; and for these reasons 
the diagnosis becomes of less practical importance, though the ten- 
derness of the abdomen would generally enable us to distinguish 
peritonitis from uncomplicated mesenteric disease. In the case of 



DIAGNOSIS. 351 

worms and infantile remittent fever, though there may be pains in 
the abdomen, they may be readily distinguished from chronic peri- 
tonitis, both by the general symptoms and by manipulation of the 
abdomen. For a diagnosis between this disease and phthisis pulmo- 
nalis we must again have recourse to a careful observation of the 
physical signs, since the constitutional ones are often so nearly iden- 
tical ; and here, too, we may remark, that the two affections are very 
often coincident : so much is this the case, that in young persons pre- 
senting some of the symptoms of chronic peritonitis, we should insti- 
tute an examination of the chest with a view to ascertain if there be 
any early signs of phthisis, as this discovery would tend to confirm 
our diagnosis in regard to the abdominal disease ; and the practical 
question will often be, not whether either of these diseases exist, but 
which is the more advanced of the two : and it is well to bear in 
mind, that, though the majority of cases of tuberculous peritonitis 
occur in young persons under the age of eighteen, most such sub- 
jects die with phthisis pulmonalis, though not of it ; whereas, whilst 
the majority of cases of consumption occur above the age of eighteen 
or even twenty, many such subjects die with the disease which we 
have termed phthisis abdominalis, though not of it. Inflammation 
of the mucous membrane of the intestines when uncomplicated with 
peritonitis, may be distinguished from the chronic form of that dis- 
ease by the absence of superficial tenderness, the form of the abdo- 
men, the character of the evacuations, and the defined pink flush on 
the cheeks. 

Besides the general distinctions between chronic peritonitis and 
the diseases just mentioned, there are other points bearing upon the 
diagnosis to which our attention ought to be directed. Thus, in 
examining the abdomen by the hand, what appear to be tumours 
may not unfrequently be detected ; of these it would at first be 
impossible to say whether they are strumous or other masses, or 
accumulations in the intestines ; and the only mode of ascertaining 
will be to administer a gentle laxative ; as, for instance, three or four 
grains of grey powder to be followed in a few hours by a dessert- 
spoonful of castor oil, and to observe the character of the evacuations, 
and the effect upon the swelling. This may be repeated several 
times, as long, in fact, as any solid matter continues to be brought 
away, after which it will often be found that the supposed tumour 
has disappeared. The removal of such swellings by these means is 
not, however, conclusive against the existence of chronic peritonitis, 
since, as has been pointed out, it may be the cause which has rendered 
the intestines liable to such accumulations. 

Besides the general diagnosis of the presence of peritonitis by the 
signs which have already been detailed, we may often arrive at a 
greater degree of certainty, not only as to its existence, but also its 
character, extent, and situation, by careful manipulation, and even 
oscultation : thus, when exploring the abdomen by the hand and fin- 
gers — besides the deviations from its natural elasticity and the points 
of tenderness complained of by the patient, a certain crepitation is 
felt, under the fingers, which has been, not unaptly, compared to the 



352 CHRONIC PERITONITIS. 

moving of greased surfaces one over the other ; — this will indicate 
fresh or unorganised lymph, corresponding to the part where it is 
felt. Again, the application of the stethoscope will often detect, 
especially towards the margin of the ribs, a dry friction sound, or a 
soft crepitating one, not unlike that which has been termed mucous 
crepitation : the former of these is indicative of old fibrinous effusion, 
and the latter of recent and soft lymph. These phenomena will 
sometimes enable us to define the boundaries of the effused lymph 
with remarkable precision. 

The chronic peritonitis which constitutes one form of ascites, and 
which often presents no symptoms before the occurrence of the effu- 
sion, is to be distinguished from ovarian dropsy by the absence of 
those signs which characterise the encysted form of the latter, though 
from hepatic dropsy the diagnosis is not so easy ; it may, however, 
be inferred, from the absence of the symptoms and the previous his- 
tory which belongs to the latter, as well as from the greater hardness 
and more globular form of the abdomen. 

The prognosis of chronic peritonitis is, in the majority of cases, 
unfavourable, though we are not to conclude that it is at all times 
necessarily so. When the disease is the result of previous acute 
peritonitis, there is great danger from the liability to intestinal ob- 
struction, arising either from adhesions, from bands of false mem- 
brane pressing upon the intestines, or from the loss of contractility 
induced by the inflammation. Such cases may, however, under 
careful management, apparently recover, and the patient escape any 
serious inconvenience, though the possibility of his having at any 
time a dangerous attack of intestinal obstruction is not to be lost 
sight of, especially when a question arises as to the probable value of 
his life. These remarks apply, though not perhaps with equal force, 
to the case of females in whom the disease has ocurred from uterine 
or ovarian affection. Of strumous peritonitis, it may be said that 
the disease is only less dangerous than pulmonary consumption, and 
it is hard to give any reason why it should be so at all, unless it be 
that the access of air in the lungs causes a softening of the tubercu- 
lated portion of the organ, and consequent destruction of the sur- 
rounding tissue, which does not take place in the closed peritoneal 
sac. The occurrence, too, of symptoms of strumous peritonitis in 
young persons of phthisical families might be supposed to have an 
unfavourable bearing upon their prospects as regards their liability 
to phthisis at a maturer age. Yet, strange as it may appear, cases 
have occurred in which there have been well-marked signs of early 
phthisis pulmonalis coexisting with undoubted chronic peritonitis, 
where the development of the latter disease seemed to exert a revul- 
sive influence in arresting the progress of the former. 

This was unmistakeably the case in a patient to whom allusion 
has been already made, who recovered after the escape of a large 
quantity of puriform matter by the umbilicus, and in whom there 
were oscultatory signs of incipient, or, to speak more correctly, early 
phthisis. In the chronic serous peritonitis or peritonitic ascites, the 
prognosis is also unfavourable, though even here, as has been pointed 



TREATMENT. 353 

out, the effusion may sometimes disappear after profuse watery dis- 
charges. 

The treatment of chronic peritonitis must be conducted with the 
greatest caution, the object being first to avoid all needless excite- 
ment of the peristaltic action, of the intestinal canal, which has the 
effect of aggravating the inflammatory action where it exists, and 
exciting it afresh where it has subsided ; — secondly T to check any 
tendency to acute inflammation which may arise in the progress of 
the disease ; — and thirdly, to correct that condition of the constitu- 
tion upon which it so frequently depends. In the subacute disease, 
which is a sequel of the acute, we must carefully look for any indi- 
cation of fresh inflammatory action arising in particular parts, and 
when this is the case, we must, where the powers of the patient 
admit, apply a few leeches over the affected part. After this blisters 
may be occasionally used, or stimulating liniment applied to the 
abdomen ; hot fomentation or warm poultices of linseed meal will 
often give much relief when the pain is urgent. Our next object 
should be to reduce the tendency to chronic inflammatory action ; 
this will, perhaps, be best affected, in the class of cases of which we 
are now speaking, by the moderate and carefully regulated use of 
mercurial preparations : these are generally best combined with 
opium to prevent irritation of the bowels, and there is, perhaps, no 
better form than one grain to a grain and a-half of calomel with 
three or four of compound soap pill twice or thrice a-day, watching 
at the same time most carefully for the signs of the specific action of 
the mineral, in which case it should be immediately withdrawn, or 
at all events, reduced to one dose in the day ; for the continuance of 
slight mercurial action is, perhaps, desirable in those cases in which 
emaciation and general exhaustion are not great, and we have good 
reason to believe that the disease is not of a tuberculous charac- 
ter. When the bowels are sluggish, as they often are in this form 
of chronic peritonitis, the most gentle laxatives must be used ; per- 
haps there are few better than the hydr. cum cret. and castor-oil, 
but should the bowels be obstinate, we must on no account attempt 
to force an action by strong purgatives. As a general rule in cases 
of this kind, those aperients which appear to soften the contents of 
the bowels, by promoting the secretion from its lining membrane, 
are to be preferred, whilst those which act more by exciting the 
action of the muscular coat are to be avoided. When the action of 
the bowels is torpid and there are occasional pains, the combination 
of hyoscyamus, liq. potassae, and sp. nit. asth. will be found very ser- 
viceable, and to this may be added a little pot. iodid., say two grains 
to a dose, which will often promote the absorption of effused matter. 
The occasional use of soap enemata is also to be recommended. As 
the patient recovers, pure air and gentle exercise are incomparably 
the best tonics for restoring the tone and contractility of the muscu- 
lar coats of the intestines, as well as promoting absorption so far as 
it can be affected. 

In those cases in which, from the signs we have here pointed out, 
there is reason to believe the peritoneal inflammation to be of a 

23 



354 CHEONIC PERITONITIS. 

strumous character, we must be even more upon our guard to avoid 
depressing the powers of the patient, and especially cautious in the 
use of mercurials: when there is any great increase of tenderness, 
and reason to apprehend the supervention of acute inflammation, a 
few leeches may be applied to the part, and we may venture upon 
about a grain of calomel, or two or three of hydrarg. cum cret., with 
four or five of pulv. ipecac, co. night and morning; and when the 
pulse is softened, and the skin cooler, a blister may be applied. At 
the same time with these remedies, we may also administer one of 
the accompanying mixtures (F. 62),* the former to be preferred if the 
urine be scanty. Should there be no symptoms of intercurrent acute 
peritonitis, or as soon as they have subsided, the iodide of potassium 
may be used with advantage, in doses of from a grain and a-half to 
three grains; and will be best given with the first mixture. At this 
period of the disease we must direct our attention as much to the 
strumous diathesis of the patient as to the local disease, and therefore 
diet and general mode of life become of the greatest consequence. 

In regard to diet, we must remember that we are probably exposed 
to disease in the mesenteric glands and the lymphatics, and that the 
stomach and bowels are prone to be either irritable or torpid in their 
action. At the same time we must endeavour to convey into the 
system the greatest amount of nutritious non-stimulating aliment 
that it is capable of receiving and assimilating. 

In promoting the recovery after the severer symptoms have sub- 
sided, or preventing their invasion, where there is reason to appre- 
hend them, the importance of pure air and light are not, perhaps, 
sufficiently estimated. Children in whom there exists any indica- 
tions of a strumous diathesis should, at all times, be kept in as pure 
an air as circumstances admit of; and not only should this be carried 
out by residence in the country in elevated situations, or by the sea- 
side, but also by their spending a large portion of their time in the 
open air. A moderately warm clothing, covering pretty uniformly 
the whole surface, is not only essential for the sake of equalising the 
circulation, but also enabling them to spend much time in the open 
air without risk. Exposure to the direct solar ray, unless the heat 
be great, or, at all events, the free admission of light, is no incon- 
siderable preventive to the establishment of strumous disease. 

In the chronic serous peritonitis or peritonitic ascites, we may use 
mercury somewhat more freely; the combination of squill and blue 

* (62) R. Liq. Potassse, ^ iii. 
Tinct. Hyoscy. g iv. 
Sp. JEtk. nit. g v. M. 
A small spoonful to be taken in a glass of barley-water. 

Or, $. Sodas B''carb. gr. xiv. 

Tinct. Hyoscy. vr L xx. — xxx. 
Sp JEtk. nit. g ss. 
Mist. Acac. £iv. 
Sp. Pimentse, 3 ii. 
Aq. purse. 
A sufficient quantity to make a ^ iv. mixture, of wkick tke tkird portion is to be 
taken at a time, and repeated thrice in tke day. 



TREATMENT. 355 

pill being in general the preferable form, or the following pill (F. 63)* 
may be administered three times daily, saline diuretics being given 
in the intervals, to which may be added from one to two drachms of 
infusion of digitalis, provided the effect upon the pulse be carefully 
watched. Hydragogue cathartics in the form either of pulv. jalap 
co., of elaterium with bitart. of potass, being exhibited from time to 
time (F. 64).f Should the swelling continue, and the urine not be 
increased after the mouth has been slightly affected by the mercury, 
the iodide of potassium should be tried, which may be administered 
in the form prescribed above. As, however, these and all measures 
for promoting the removal of the fluid by absorption will, in many 
cases, prove unsuccessful, it will often be necessary to have recourse 
to paracentesis, though the operation is, under such circumstances, 
not without danger, owing to the peritoneum being already in a state 
of chronic inflammation, and any considerable tenderness, sharpness 
of pulse, or other inflammatory symptom, should be received as a 
contra-indication. When the operation is determined upon, it would 
be well to have recourse again to the mercury, until the mouth is 
slightly affected, when paracentesis may be performed. When the 
pulse is feeble, a small trochar should be used for this purpose, the 
abdomen carefully bandaged, and a grain of opium administered 
with a grain of calomel. After the patient has recovered from the 
immediate effect of the operation, diuretics with the iodide of potas- 
sium may be resumed. 

• 

* (63) R. Pulv. Digitalis, gr. j. 
Pil. Hydrarg. gr. i. 
Pil. Scillse co. gr. iij. 
Ft. Pil. 

f (64) R- Extract Elater. contriti, gr. %. 
Pot. Bitart. gr. xvj. 
Zingiberis contriti, gr. ij. M. 
To be well combined in the form of a powder. 



356 SYMPTOMS OF ENTERITIS. 



■X..A.. 

ENTERITIS AND OBSTRUCTED BOWELS. 

Enteritis is a term, the meaning of which, as used bj different 
authors, it is not very easy to define. Some appear in speaking of it 
to contemplate inflammation of the mucous membrane, others that of 
the serous. Dr. Watson, with his accustomed fondness for simplicity , 
interprets it as inflammation of the bowels, by which he means 
inflammation of the serous membrane, the muscular and areolar 
tissues, and the mucous membrane, of a portion of intestine : and this 
is the sense in which we purpose to apply it, 

It is very doubtful if this disease is ever a primary one: most 
authors speak of the inflammation as arising in the peritoneal coat, 
and extending from thence to the other tissues of the intestine ; but 
we have seen that primary peritonitis is a very rare occurrence. 
Still, as enteritis is spoken of as a primary lesion by many authors 
of reputation, as it is one which we not uncommonly meet with as a 
consequence of some antecedent disease or irritation, as, above all, 
it is a disease of the greatest danger, proving fatal if not relieved in 
a short time, and requiring the most careful discrimination as to its 
diagnosis and treatment, it is necessary to be well acquainted with its 
nature and symptoms. 

Enteritis may commence with some very well marked pain, or 
extraordinary sensation in the abdomen: patients have more than 
once spoken to the author of the first symptom having been a sense 
of something having given way or becoming twisted or displaced. 
In some cases there are rigors. The pain, which, is at first circum- 
scribed, rapidly becomes more and more intense, and extends over 
the whole abdomen. There may not be much tenderness at the 
commencement, but in a short time it becomes so severe that the 
slightest pressure, even that of the bed-clothes, cannot be borne. 
The pain in enteritis is incessant, though it is subject to paroxysms 
of aggravated intensity ; in this respect it differs from that of colic, in 
which the pain comes on in paroxysms, and entirely subsides in the 
intervals. It will sometimes happen that at the very commencement 
of the attack there will be copious relief of the bowels, after which 
they become obstinately constipated. Nausea and vomiting super- 
vene sooner or later, though the period at which this happens varies 
according to the seat of the disease. The vomiting is often highly 
offensive, having an odour of faeces, and thence called stercoraceous, 
showing that the matter ejected has been brought up from the lower 
part of the canal, though most probably not lower than the ileum. 
The sufferings of the patient are most distressing ; he lies on his back, 
with his knees drawn up to relax the abdominal muscles. The res- 
piration is hurried and mostly thoracic; and the movements and 
position all evince an apprehension of pressure or disturbance of the 



DIAGNOSIS. 357 

inflamed part; so that though there may be jactitation of the extremi- 
ties, the trunk is kept perfectly quiet. The countenance, as in peri- 
tonitis, is expressive of great distress. The symptoms are generally 
at the commencement those of inflammation of a serous membrane, 
which, from the implication of a mucous one, from its intensity, and 
often from its situation, speedily assumes a very depressing character. 
Accordingly, the pulse may be at first full and hard, but speedily 
losing the former character, whilst it retains its hardness, it becomes 
wiry, and as the disease advances, thready and almost imperceptible. 
If the inflammation do not subside, the distress and exhaustion of the 
patient increase, the pulse becomes smaller and smaller, and at last 
imperceptible, the skin clammy, and death takes place from failure, 
or rather depression of the heart's action. In some instances, the 
pain suddenly ceases some time before death: this used, as in the case 
of peritonitis, to be referred to gangrene, but that is not always found 
to have occurred ; it is probably the effect of nervine exhaustion. 

The above constitute the essential symptoms of enteritis, and may 
be summed up as consisting of those of intense inflammation in the 
abdomen, to which are added those of the hzsa partis functio, in the 
form of arrested action of the bowel, and its consequences. There 
are, however, several which may be termed accidental symptoms, 
about which a good deal of discrepancy will be found in different 
authors ; the explanation of which is that these are referable to the 
cause of the inflammation, and the part of the intestine affected by it, 
both which may vary. 

Now a common, perhaps the most common cause of enteritis, is 
mechanical obstruction, of which we shall presently speak more fully ; 
and hence we have shrinking or swelling of the abdomen ; — vomiting 
coming on among the first symptoms, or not till towards the close of 
the disease ; — scanty and high-coloured, or abundant and pure urine, 
according as the obstruction is seated near the commencement, or the 
termination, of the canal. All these, then, have been enumerated 
amongst the symptoms of enteritis. If the occlusion have taken 
place in a portion of intestine near the yielding parts of the abdominal 
parietes, there will be generally a local tumescence ; but if more 
deeply seated, there will be no appreciable swelling. 

In some instances, though these are not the most frequent, the 
inflammation appears to have arisen spontaneously, or at least inde- 
pendently of any mechanical cause. Where this has been the case, 
a portion of the bowel is dark, almost livid, having the peritoneal 
coats covered with flakes of lymph, and the mucous lining with 
sanious mucus, the intestine being at this part much dilated, though 
below it the canal is empty and firmly contracted ; this contraction 
being the effect, and not the cause, of the obstruction above. 

In some of these cases we can, as we have said, assign no cause 
for the inflammation, though in many there can be little doubt that 
it has been set up in the following manner : — Irritation proceeding 
from some indigestible matter in the canal; — a strong purgative, to 
remove the cause of that irritation ; — another purgative to overcome 
the obstinate constipation which has resulted from the increased 



358 OBSTKUCTED BOWEL. 

irritation induced by the first; — enteritis and its disastrous conse- 
quences. It is to this form of enteritis, occurring in the small intes- 
tine, that the term ileus, or iliac passion, has been applied. Another 
class of cases, in which the inflammation commences in the caecum 
and appendix vermiformis, are those in which a cherry-stone, a lump 
of hardened fseces, or even a pill, has been found in the latter, though 
it is more than probable that there was some pre-existent disease to 
allow of its intrusion : in these the pain and tenderness commence 
in the region of the caecum, where there is also some tumefaction. 
Closely resembling these cases are those to be noticed presently, in 
which peritonitis and enteritis appear to have been set up by disease 
in the ovary. 

The diagnosis of enteritis from colic depends upon the tenderness ; 
the pain of the latter being relieved by pressure, the persistence of 
the pain — the sickness — and the signs of acute inflammation. It is 
of course essential to ascertain that there is no hernia to be detected, 
and all the outlets should be most carefully examined. 

The treatment of enteritis rests upon the simple principles of sub- 
duing the inflammatory action by such measures as the strength will 
admit of, and keeping the inflamed part at rest. When the patient 
is seen early, and the pulse is moderately full, as well as hard, vene- 
section to the first signs of fainting is admissible ; and it will often 
happen that this will be followed by a spontaneous action of the 
bowels; leeches may also be applied to the seat of tenderness. Pur- 
gatives should on no account be given; but the patient must be put 
upon the use of calomel and opium in equal parts. The pain often 
renders the tolerance of opium great, so that eight or ten grains of 
each may often be given in the course of twenty -four hours. The 
occasional use of a soap enema is admissible. We must not forget 
the tendency to death by asthenia in this disease ; and when the 
extremities become cold, or the pulse very feeble, wine or brandy 
should be given. When the action of the mercury begins to show 
itself on the gums, it should be withdrawn, and the opium steadily 
persevered with. 



OBSTKUCTED BOWEL. 

By obstruction of the bowels is here intended that degree of con- 
stipation which resists the use of ordinary remedies ; and although 
this obstruction may arise from such a variety of causes that it is 
impossible to classify it in any strictly pathological arrangement, yet 
it is a condition of such extreme importance in practice, and one the 
mismanagement of which is so eminently dangerous, that we proceed 
to speak of it as one disease, though the causes of it may be various ; 
and though our treatment must be in a great measure guided by our 
discrimination in detecting the principal one. And therefore, before 
proceeding to describe the disease, we shall enumerate them. 

These causes may be either inflammatory, as in the case of perito- 
nitis or of enteritis; or obstruction may be the secondary effect of 



ITS HISTORY. 359 

inflammation, as in the case — of the impeded peristaltic movement, 
from adhesion of one portion of bowel to another, or to some neigh- 
bouring viscus, or of constriction by a band of false membrane, or — 
of the diminished contractility of the muscular coat which ensues 
upon and may continue after peritonitis or enteritis. It may also be 
produced by chronic disease, whether inflammatory or otherwise, 
causing contraction or thickening of the coats of the intestines; — or 
it may arise as a consequence of any of the above, the delay in the 
passage of the contents setting up a distension behind it; and this 
distension, of a coil of intestine for instance, may cause its displace- 
ment (as by rolling over), and a consequent twisting of the bowel. 
The same thing may be produced, especially in the large intestines, 
and this, more especially about the sigmoid flexure, by habitual 
costiveness (induced in many instances by neglecting the calls of 
nature), the distended portion of the bowel having been ascertained 
in one instance to have rolled twice over. Analogous to these cases 
of twisting and strangulation, are those with which the surgeon is 
familiar, as arising from hernia, which should always be carefully 
searched for ; but hernia may exist without being apparent exter- 
nally, as in the case of hernia at the obturator foramen, or a loop of 
intestine passing through some advantitious ring formed by false 
membrane. 

Inflammatory action in the inner or mucous coat of the intestinal 
canal does not commonly produce obstruction, though it is to be 
remembered that dysentery causes a delay in the passage of foecal 
matter; and ulceration of the stomach, or duodenum, often produces 
considerable constipation. Ulceration of the bowel may also cause 
delay in the passage of its contents, in order, seemingly, to allow 
time for the process of reparation. Obstruction again may also arise 
from the accumulation of hardened fasces, generally in the colon, as a 
consequence of diminished contractility, either from inflammation or 
over-distension ; and hardened faeces, or the presence of a forcing 
body in the appendix vermiformis cseci, produces constipation of 
peculiar obstinacy and urgency of symptoms. Another cause of 
obstruction may be intus-susception, or the passing of a portion of 
intestine into that immediately below it, and its becoming invaginated 
therein. 

Besides these causes we may have others arising from a loss of 
natural irritability, or an insensibility to the natural stimulus, as in 
the effect of lesion of innervation ; analogus to retention of urine from 
paralysis of the bladder. 

These cases commonly present themselves under somewhat of the 
following circumstances: the patient, who may previously have 
enjoyed good health, has felt some sudden pain, sometimes as of a 
sense of falling or twisting in the abdomen, which in some instances 
is followed immediately by faintness or sickness, or both; in others 
there may be for a short time no unpleasant symptoms. The bowels 
not acting, however, the patient often of his own accord takes a pur- 
gative, which he may even be induced to repeat. Either these medi- 
cines are rejected, or the patient suffers much from weight and dis- 



360 OBSTRUCTED BOWEL. 

tension of the abdomen: in this condition, and becoming anxious at 
getting no relief of the bowels, he seeks for medical advice. Again, 
in some cases there may have been previous tenderness in the abdo- 
men, with irregular action of the bowels, before the supervention of 
these symptoms. In others, again, we may elicit a history of some 
former peritonitic attack ; or again, there may have been no well- 
defined sj^mptoms, but simply a cessation of the action of the bowels, 
and subsequent weight and distension ; or the distressing sensations 
may have come on speedily after partaking of some indigestible food. 
Such is the general history of obstructed bowel; yet upon close 
inquiry we shall find very different and even opposite symptoms in 
different cases. 

Our first business in cases of this kind is carefully to explore the 
abdomen, in order to ascertain if any external hernia exists. If this 
examination, which ought always to be most carefully conducted, 
reveals nothing of the kind, we proceed to ascertain, as far as pos- 
sible, the seat and character of the obstruction, by examination of 
the degree of tenderness of the abdomen or of any part of it, con- 
sidered in connection with the character of the pulse, the position of 
the patient, and the degree of pain caused by motion. Should a rather 
sharp and hard pulse, with considerable pain, aggravated by pressure 
or motion, induce us to believe that there is some peritoneal inflam- 
mation, we must not infer that such inflammation is the primary 
cause of the obstruction, as the very existence of the obstruction may 
of itself give rise to inflammation, especially if active purgatives have 
been used. If, however, there be no sign of inflammatory action, we 
may conclude that the obstruction is caused either by accumulation 
in the bowel, by loss of contractile power, as in colic, or by twisting, 
intus-susception, or constriction by some bridle of false membrane. 
Our next examination should be as to the degree of tumescence of 
the abdomen, for in this respect we observe two opposite conditions ; 
in the extreme case, for instance, of obstruction in the duodenum, 
the abdomen is flat or even sunken ; in the opposite one, of obstruc- 
tion at the sigmoid flexure, we have a very tumid and resonant abdo- 
men; intermediate obstructions will give intermediate degrees of 
fulness. Sickness, again, is a very important symptom. When the 
obstruction is high up in the canal, sickness will be early and inces- 
sant; when it is in the colon there is no sickness, except what may 
be excited by irritating medicines, till the obstruction has lasted some 
days. In obstruction in the course of the lower part of the jejunum 
or ileum, we have early sickness, but not so immediate or so urgent 
as in the case of the duodenum. The condition of the urine is most 
important as regards the diagnosis of the seat of the obstruction; 
when the obstruction is high up, as in the duodenum, the quantity 
of urine is so small, or rather the suppression so complete, that cases 
of this kind have been mistaken, and that too by men of experience, 
for ischuria renalis ; whereas, when the stoppage has been very low 
down, as in the sigmoid flexure for instance, the urine is abundant 
and clear. In the first case the suppression of the urine may in a 
great measure be accounted for by the sickness; it may be observed, 



MODE OF INVESTIGATING. 861 

however, that sickness as ordinarily observed, independent of me- 
chanical occlusion near the stomach, never suppresses the secretion 
so completely. In the case of obstruction in the descending colon, 
as there is no sickness, and as there is delay in the passage of its con- 
tents along the intestinal tube, there is abundant opportunity for 
absorption; and therefore, from the large quantity of fluid taken up 
by the veins, the quantity which passes out becomes large. 

There is another circumstance which deserves investigation when 
we would ascertain the character or seat of the obstruction, and that 
is the degree of contraction of the lower bowel as carefully explored 
by a bougie, or the oesophagus tube. When sudden obstruction 
takes place in any part of the alimentary canal, it generally happens 
that the whole of the bowel below this part speedily and even forcibly 
empties itself; and this perhaps applies more particularly to the small 
intestines, where obstructions, when they do occur, are generally 
from twisting, intus-susception, or acute inflammation, as enteritis. 
This not only produces the flatness of the abdomen above alluded to, 
but even a forcible contraction of the rectum, such as in one instance 
to have induced a doubt of the diagnosis of obstruction high up in 
the small intestines, from the fact that it was almost impossible to 
introduce the tube or even the finger in the rectum ; so forcibly did 
the bowel contract through its whole course below the closure. And 
the same thing occurs in sudden occlusion, or sudden stoppage from 
inflammatory affection, in the large intestines: thus, in those unfor- 
tunate cases in which this mischief ensues from the presence of a 
foreign body in the appendix caeci, the whole of the large intestines 
completely empty themselves, and afterwards no action takes place. 
When, however, the stoppage takes place from chronic thickening or 
contraction, or from malignant disease, occurrences which are more 
likely to take place in the large intestines, the bowel often loses its 
contractility below as well as above the seat of obstruction; and, 
therefore, the rectum upon examination by the finger will often be 
found dilated; so that upon the introduction of the oesophagus tube 
it will often coil upon itself in the pouched bowel, which may lead 
to a belief that it has passed a considerable distance up the canal. 
This condition rather favours the supposition that the obstruction is 
produced by chronic or malignant disease, seated probably in the 
large intestine. The examination of. the bowel with a bougie is not 
without danger; since the instrument passing readily through the 
dilated portion, may be brought too forcibly in contact with the side 
of the bowel, just at the seat of the obstruction, near to which there 
is not uncommonly ulceration. Examination of the lumbar region is 
also important in determining the seat of obstruction: when it is in 
the small intestines, the caecum, or even the ascending colon, there 
will be no great fulness in the right loin — but if it be in the trans- 
verse or descending colon, we generally find a bulging in that region, 
which when the obstruction is remote, (as in the descending colon or 
sigmoid flexure,) will generally be very resonant on percussion, from 
the accumulation of flatus ; but if the stoppage be nearer, as in the 
transverse colon, it may be dull from the accumulation of fa?eal mat- 



362 PROGNOSIS AND TEE A THEN T. 

ter. If upon similar examination the left loin also be found bulging, 
the obstruction is in the sigmoid flexure ; and if there be also great 
resonance, it is probably at its termination in the rectum. It may 
not be amiss to observe that the sigmoid flexure may, under these 
circumstances, rise up above the crest of the ilium, and produce 
tumescence, with resonance, in the left lumbar region, which may 
cause it to be mistaken for the descending colon; a circumstance of 
no great practical importance as regards the diagnosis, but which 
deserves grave consideration when any operation is proposed to 
be performed in that region, with a view to relieving the obstruc- 
tion. 

The prognosis of obstruction of this kind must of necessity depend 
upon its cause, and it has generally been assumed that where the 
disease has been of such a nature that it would not yield to active 
purgatives, it was necessarily of a fatal character. The experience, 
however, of the last ten years has done much to correct this opinion ; 
and though we must still view every such case with great apprehen- 
sion, we are not warranted in pronouncing it necessarily fatal. In 
reference, however, to this view of the subject, the fact of much pur- 
gative medicine being in the intestines is not to be overlooked in 
forming our prognosis, and constitutes an unfavourable element. A 
variety of symptoms have been laid down by various authors as 
warranting an unfavourable prognosis. Amongst these we find 
nausea, vomiting, pain, tenderness and tumefaction of the abdomen, 
and high-coloured urine; and these are not without importance, 
though they never occur together, and, indeed, may be said to be 
incompatible with each other ; and experience has shown us that as 
many as can co- exist may do so, and yet the patient recover. They 
show, howeA'er, either that the disease is high up in the alimentary 
canal, in which case it is, if not soon relieved, more speedily fatal; 
or that it is in the large intestines, and the nature of the obstruction 
such that the distension, perhaps inverted action, has been propa- 
gated high up the canal. The correct view of the matter in the pre- 
sent state of our information is, that all such cases are dangerous; 
but unless we are certain as to the cause, which we never can be 
unless there be external hernia, or stricture can be detected by 
examination per anum, they are not hopeless. It is by no means 
certain that intus-susception is necessarily fatal unless aggravated by 
stimulating purgatives, and in the apparently no less desperate case 
of a foreign body in the appendix vermiformis, we have yet to learn 
that recovery or relief are impossible under appropriate treatment; 
more especially as we know that such bodies sometimes are expelled 
by ulceration through the walls of the abdomen. It may, how- 
ever, be remembered, that as regards the prognosis of intestinal ob- 
struction; obstruction in the small intestines is fatal more speedily 
than that lower down, and that the same remark applies to those 
depending upon inflammatory affections as compared with those 
resulting from chronic thickening: but that these latter, unless in a 
situation to be relieved by operation for artificial anus, are of all 



OBSTRUCTED BOWEL. 36 



o 



obstructions the most certainly fatal, not excepting even internal 
hernia. 

It is now generally admitted by all rational practitioners, that, 
after moderate purgatives have failed, it is advisable to adopt gentler 
measures and to rely chiefly on enemata, and not, in the words of 
Dr. Copland, " to prescribe medicines which will irritate and invert 
the action of the upper part of the tube without ever reaching the 
seat of the obstruction." But it has not been so generally considered 
that they may produce serious mischief, even when they do not invert 
the action of the tube, and when they do reach the seat of the ob- 
struction ; for it must be evident that in cases of mechanical obstruc- 
tion purgatives must produce much irritation immediately above it, 
and increase the already existing evil of ulceration. In those cases, 
too, in which the constipation is the effect of a conservative arrest, on 
the part of nature, of the peristaltic action of the intestines, the action 
of a strong purgative destroys the only chance of escape for the 
patient. A remarkable instance of this kind used to be related by 
the late Mr. Bransby Cooper. The patient, who had resided much 
in a hot climate, had previously suffered from attacks of constipation, 
which Mr. Cooper inferred, from his account, to have arisen in the 
manner just alluded to, in order to allow the closure by means of 
adhesion to a neighbouring viscus, or to the abdominal walls, of a 
perforating ulcer of the colon. A powerful purgative was however 
administered, contrary to the advice of Mr. Cooper, and produced 
fatal extravasation into the peritoneum. Seeing then that in cases 
of obstinate constipation no reliance can be placed on strong purga- 
tives, especially when administered by the mouth, and that much 
mischief may arise from the incautious use of such medicines, the 
question remains, what is the best course to be pursued ? 

Supposing for instance, that from the early severity of the symp- 
toms, from the sharp and wiry pulse, and urgent vomiting and scanty 
urine, we have reason to believe that the cause is inflammation, affect- 
ing the serous or muscular coat of the intestines, or both, and that 
probably high up in the intestinal tube, the principles upon which 
we must act, are, the subduing the inflammatory action by general 
antiphlogistic measures, as far as they are admissible. Thus, for 
instance, when the pulse is firm and the heart's action not depressed, 
a full bleeding will be of great assistance, and not unfrequently speed- 
ily followed by an action of the bowels ; and upon the same princi- 
ple local depletion may also be used with caution. The next, and 
perhaps more important principle, is to favour the subsidence of the 
inflammation by quieting as much as possible the inflamed or irri- 
tated part. For this purpose our chief reliance is upon opium. 
With the opium calomel may be indeed combined ; but increased 
experience tends to show that this latter remedy, so far from being 
the more important, must be used with great care ; the calomel, 
indeed, has the advantage of softening the contents of the alimentary 
canal, and thereby facilitating their passage, and it sometimes hap- 
pens that a free action of the bowels takes place just as the ellect of 



364 TREATMENT. 

the mercury begins to show itself upon the system ; but the mineral 
should be withdrawn upon the first signs of ptyalism, and if there 
have been no effect upon the bowels the opium should be continued. 
The best rule by which to be guided under such circumstances is the 
pain. These cases are almost always attended with pain, and conse- 
quently require a considerable dose of opium to procure sleep ; 
therefore, when the patient sleeps we may infer that he is sufficiently 
under its influence, and he should not be aroused to take it. In the 
intervals, however, the opium may be given in doses varying from 
one to two grains every three or four hours. A very convenient 
form for its administration is the pil. sap. co. of the Pharmacopoeia ; 
and when it is thought desirable to use larger doses than one grain 
of opium, an additional quantity may be added to the pill, e. g. (F. 
65).* This plan may be sometimes pursued for several days before 
any decided effect is produced ; but at the end of that time free evac- 
uations will often ensue, so much so that the patient may be heard 
to complain that the pills are " too powerful." 

When from the less urgency of the symptoms, from the free 
secretion of urine, and the gradually increasing size of the abdomen, 
we have reason to believe that the obstruction is in the lower part of 
the canal, and that it is probably of a mechanical rather than an 
inflammatory character, we must, as in all cases, first make the most 
careful examination, lest by any means the existence of hernia should 
be overlooked ; and having done this we may proceed to explore the 
bowel most carefully. 

If we cannot by the bougie or oesophagus tube reach the seat of 
the stricture, we must continue the opiate, and wash out the bowel 
from time to time with the stomach-pump ; but if these means fail, 
or if there be evidence of stricture in the rectum, the question arises 
as to whether an operation should be performed. That it has suc- 
ceeded is true, but it has more often failed. Improved diagnosis and 
great surgical skill may increase the number of the successful cases ; 
but in the meantime, we must, as Heberden said, in his day, of the 
operation for strangulated hernia, " have a dread of directing such a 
hazardous operation too soon, or such a painful one too late." 

* (65) R. Pil. Saponis co. gr. xvj. 
Opii, gr. ij— iv. Misce. 
Ft. Pii. iv. 



MUCO-ENTEKITIS. 365 



XXI. 

MUCO-ENTEBITIS, TABES MESENTERIOA, DIAEEHGEA 

AND DYSENTEEY. 

Like the mucous membrane of the stomach, that of the small 
intestines is liable to inflammation, both acute and chronic. To this 
disease we apply the term muco-enteritis, though some authors 
appear to have spoken of it under that of enteritis. 

This affection commences with a deep-seated pain, which is gene- 
rally about the right iliac region, which, by degrees, spreads itself 
towards the umbilicus, and over the whole of the abdomen. This 
pain is generally increased by moderately firm pressure, though there 
is nothing like the excessive tenderness of acute peritonitis. The 
bowels are often at the first constipated, but they shortly become 
relaxed, and sometimes they are so from the first ; the evacuations 
consisting of thin mucous or serous matter, variously tinged with 
bile or faecal matter, and highly offensive. The action of the bowels 
is generally preceded and attended by much griping pain, and a con- 
siderable evolution of offensive flatus ; there are also frequent aggra- 
vations of pain, from the passage of irritating gaseous or other matter 
through the inflamed portion of the intestine. The constitutional 
symptoms are not ordinarily of a very severe character ; there may 
be no well marked symptoms of the invasion of pyrexia, though in 
many cases there are chills alternating with flushings of heat. The 
skin is commonly warm rather than hot, though the extremities are 
apt to be cold ; it is also uncertain as to moisture, but in most cases 
moist and dry by turns. The countenance is commonly pale, though 
there is often at intervals a circumscribed flush on one or both 
cheeks. The pupils are apt to be rather dilated. The pulse is gene- 
rally accelerated, rather sharp, but compressible, the tongue coated 
with a whitish fur towards the centre, the tip and edges red, with 
elongated papillae. The urine is scanty and high-coloured, sometimes 
turbid with urates. There is considerable thirst. 

In the majority of cases, the symptoms gradually subside after a 
few days. The thirst abates, the pain and tenderness become less, 
the diarrhoea ceases, and the evacuations resume their natural con- 
sistence. In some instances, on the other hand, generally occuring 
in subjects of feeble or strumous constitutions, the purging increases 
and becomes incessant ; there is sickness, emaciation, extreme pros- 
tration, rapid flickering pulse, glazed tongue, and death from asthenia. 
These latter cases, however, are almost always complicated with 
disease of the mesenteric glands, and often with strumous peritonitis, 
constituting the tabes mesenterica to be presently noticed. In some 
instances, too, the inflammation extends to the muscular and peri- 
toneal coats, and assumes the form of enteritis. Perforation from 
ulceration may ensue, and fatal peritonitis be the result. 



366 CHROMIC MUCO-ENTERITIS. 

The anatomical change connected with muco-enteritis is active 
congestion of the mucous membrane, showing itself in finely-arbor- 
escent injection of the vessels, most intense in the valvulse con- 
niventes. where there are here and there superficial ulcerations. 
There is also, as in bronchitis, inflammatory turgescence of the sub- 
mucous areolar tissue, and in very severe cases flakes of albuminous 
matter. The causes of muco-enteritis are — checked perspiration, 
irritating matters taken into the canal, as id digestible articles of food, 
shell-fish, stale vegetables, sunripe fruits, drastic purgatives, &c, and 
very cold drinks taken when the body is overheated. It some- 
times is a consequence of continued fever, and it frequently follows 
severe burns or scalds, and the retrocession of chronic diseases of the 
skin. 

Muco-enteritis may be distinguished from peritonitis by the absence 
of extreme tenderness, by the softer pulse, and the looseness of the 
bowels, and by nearly the same symptoms from enteritis. From 
continued fever, of which it is a frequent complication, it may be 
distinguished by the absence of the oppression and other symptoms 
of that disease. From dysentery, by the pain and tenderness not 
being limited to the course of the colon, by the absence of the 
tenesmus, and of the viscid slimy stools. 

The treatment of uncomplicated muco-enteritis should be exceed- 
ingly simple. Where there is much tenderness a few leeches may 
be applied to the abdomen, and if the bowels have not been satis- 
factorily opened, about four grains of hydr. cum cret. may be given, 
and followed in about four hours by two or three drachms of castor- 
oil, with as many minims of tincture of opium. Subsequently the 
carbonate of soda (F. 66)* may be administered, .and if the bowels 
are irritable four or five grains of pulv. ipecac, co. every night. If 
the skin be dry, and opium seem inadmissible, a few minims of vin. 
ipecac, added to the mixture, will encourage perspiration. 

The important part of the treatment consists however in the removal 
of all cause of irritation by the blandest diet. This should consist 
for some time of soft farinaceous food. 

Under the above plan of treatment, the acute muco-enteritis will 
commonly subside, unless the accidents of ulceration or the super- 
vention of enteritis occur. It may however, especially in delicate 
constitutions, pass on to the chronic form of the disease. 

Chronic muco-enteritis, besides being a sequel of the acute disease, 
may creep on in an insidious manner, often commencing with the 
symptoms of chronic gastritis, to which are gradually added those of 
muco-enteritis, in a less active though more protracted form. But 
though the symptoms may be less severe, the disease is more dan- 
gerous, the patient's strength gradually failing, and death ultimately 
taking place, it may be after a period of months or even years, often 

* (66) R. Soda? Bicarb. ^ ij. 
Mist. Acac. 3 iv. 
Syrupi Aurant. g ij. 

Aq. Menth. pip. q. s. ; to make a four ounce mixture, of which the 
one-third nortion is to be given thrice a-clay. 



PROGNOSIS AND TREATMENT. 367 

under an apparent aggravation of his symptoms, though sometimes 
from the inability of the system to resist an attack of some ordinary 
malady. 

The anatomical changes produced by chronic muco-enteritis are, 
injection of the vessels of the mucous membrane of the intestines — 
ulceration, especially about the valvulse conniventes — thickening 
and induration of the submucous areolar tissue — and sometimes, as a 
consequence, contraction of the calibre of the intestine. They are 
essentially those of inflammation of a mucous membrane, and it is 
remarkable that they are in the main confined to that membrane ; 
the mucous glands not being, as in the case of continued fever, con- 
siderably enlarged, and ulceration of them being still more rare. 

The prognosis of continued chronic muco-enteritis is in the main 
unfavourable, though the fatal termination may be long delayed; 
and this fatal tendency depends not so much upon the severity of the 
disease as the circumstances under which it commonly occurs. We 
have already seen that inflammation of the lungs or bronchial mem- 
brane may occur in subjects in whom there is deficient power of 
repair, and consequently the disease assumes a disorganising cha- 
racter, and the result is the same as when it is accompanied by the 
deposition of tubercle: and so it maybe in the bowels; common 
inflammation may assume much the character of strumous. Thus 
common inflammation of the mucous membrane may be excited by 
causes similar to those which induce the acute form of the disease, 
but from the enfeebled powers of the constitution repairs may not be 
effected. 

The treatment of chronic muco-enteritis must consist mainly in the 
removing every cause of excitement or irritation of the inflamed 
membrane. As the bowels are generally relaxed there will seldom 
be occassion for laxatives; but should they not act for more than 
thirty-six hours, and should the evacuations contain pieces of solid 
matter, two grains of hydr. cum cret. may be given, and afterwards a 
tea-spoonful of castor-oil ; or should there be no sickness the castor- 
oil with tincture of rhubarb, may be administered (F. 67).* The 
frequent use of mercury is most pernicious ; but if the bowels be 
irritable, and the motions pale, a grain of hydr. cum cret. with three 
or four of Dover's powders, may be given at night. When there is 
much tenderness, with signs of active inflammation, a few leeches 
may be applied to the seat of the pain, and afterwards a warm linseed 
poultice ; provided always that the strength of the patient is sufficient 
to justify it. The soda with mucilage (F. QQ) may also be employed, 
and if there be much diarrhoea the chalk mixture may be given 
occasionally. When the irritability of the bowels is excessive, about 
four ounces of starch, with thirty minims of laudanum may be thrown 

*(67) R. OleiRicini, 

Tinet. Rhei, ail % iij. 
Mist. Acac g iij. 
Tinct. Opii, rr^ vj. 
Aq. Pimento, 5 vij. M. 
A large spoonful or two to be given as a dose. 



368 TABES MESENTERIC A. 

into the rectum. The diet must be of the blandest and most soothinsr 
kind, consisting of soft farinaceous substances, a little plainly-dressed 
meat, if it do not cause uneasiness, and fowls or game, provided the 
latter be not high. The drink should be barley water or milk and 
lime-water ; or if there be not much flatulence a draft of equal parts 
of milk and soda-water will often be found refreshing. When there 
is much exhaustion a little arrow-root with brandy may be taken. 

Tabes mesenteric^ or, as it is sometimes more fitly called, phthisis 
abdominalis, consists essentially of strumous or tuberculous inflam- 
mation of all the tissues of the intestines, and of the mesenteric 
glands. 

This is a disease almost exclusively of infancy, childhood, or early 
youth. It may follow as a sequel of muco-enteritis, but otherwise 
the symptoms at its commencement are insidious and obscure. In 
the majority of instances there will have been previously-enlarged 
glands, tumid abdomen, or other signs of the strumous diathesis. 
The appetite of the child becomes capricious ; there will often be an 
unwillingness to take food, alternating with an almost insatiable 
craving; the complexion of the child becomes doughy, though the 
cheeks may retain their colour for some time. He afterwards begins 
to lose flesh, and the abdomen becomes more tumid, which is ren- 
dered more obvious by the emaciation of the extremities. There will 
be flushings of heat, more particularly towards evening, when there 
is often not uncommonly a bright, well-defined flush upon one or 
both cheeks. The bowels are irregular, the motions sometimes dry 
and friable, at others very relaxed, and almost always pale. The 
urine is loaded with lithates, and often there is a stain of purpurine 
at the bottom of the vessel. The tongue is covered with a creamy 
coating, through which the elongated papulge are conspicuous ; the 
breath is sourish and offensive. If the disease be not arrested in its 
earlier stages, the emaciation increases, the abdomen enlarges, and 
considerable effusion often takes place into the peritoneal cavity. 
There are frequent attacks of diarrhoea, pus or blood being sometimes 
present in the evacuations. Hectic increases, and the patient sinks 
from asthenia. 

The treatment of this disease, to be effective, must be preventive ; 
and the indications which we must endeavour to fulfil, are, first, the 
correction of the strumous diathesis; and, secondly, to prevent the 
determination of that diathesis to the abdominal viscera. For this 
end, we must endeavour to prevent or counteract those circumstances 
which have been pointed out (p. Ill) as tending to promote this 
diathesis, and in addition, the uses of the steel, wine, and cod-liver 
oil, to the extent of a drachm of each three times a-day for a child of 
four years, may be had recourse to, the bowels being regulated as 
occasion may require. We have already pointed out that childhood 
is the period in which those organs are in the state of greatest func- 
tional activity compared to the rest of the system, and therefore the 
phthisis of childhood is often abdominal. Now, although we cannot 
dispense with the functions of the alimentary canal and mesenteric 
glands, we may do much towards the rendering those functions the 



DIARRHCEA — VARIETIES. 369 

cause of the least possible irritation to the organs themselves. Thus 
the diet should be of the simplest and the blandest character, as well 
as that which is the most readily digested and assimilated. Milk, as 
containing all the elements of nutrition in a fluid state, is peculiarly 
appropriate ; but, in the earlier stages of the complaint, beef-tea, made 
according to Professor Liebig's recommendation, and even the gravy 
of roast meat, or the meat itself carefully cooked, are admissible, as 
are also light farinaceous articles of diet. 

When there is any febrile excitement, the iron and coclliver-oil 
must be suspended, and simple salines may be employed. In the 
more advanced cases, where there is much abdominal tumescence, 
and even fluctuation, we may often derive much benefit from the 
iodide of potassium (F. 68).* 

We have already alluded to diarrhoea as produced by inflamma- 
tion or irritation of the mucous lining of the small intestines, but, 
independently of this, it may arise from a variety of causes. 

Among the first of these may be reckoned the overloading of the 
stomach, and the taking of food which is indigestible. This is the 
diarrhoea crapidosa of Cullen, and proceeds from the excessive secre- 
tion poured out in consequence of the irritation set up by the quan- 
tity or quality of the ingesta. The symptoms of this form of diarrhoea 
are griping, flatulence, sometimes nausea, a foul tongue, acrid or 
rotten egg eructations, stools of unnatural appearance, very liquid, or 
even watery ; there is little or no fever or acceleration of the pulse. 

Another cause of diarrhoea is mental emotion, especially fear, the 
effect of which in this way is proverbial. A high temperature, again, 
has the same effect, perhaps by stimulating in the first instance the 
liver, the increased secretion from which excites that from the small 
intestines ; be that as it may, we certainly find diarrhoea most preva- 
lent in the hot months of summer and autumn. 

The treatment of diarrhoea must depend in a great measure upon 
our knowledge of its cause, though it must be regulated upon the 
principle of excluding every source of irritation. 

In the diarrhoea crapulosa, the purging will of itself generally 
remove the offending matters ; though, if we are called at the com- 
mencement, we may favour the process by the administration of about 
a tea-spoonful of castor oil, or the combination of rhubarb and chalk 
(F. 58). After this a day or two's abstinence upon barley-water will 
complete the cure ; though if the bowels continue irritable, it will be 
well to give a gentle opiate. 

In the case of diarrhoea from mental emotion, or that which arises 
apparently from season or external causes, the bland diet should be 
had recourse to, and if the diarrhoea do not speedily subside, a little 
chalk-mixture may be employed. If the diarrhoea persists, vege- 

* (68) R. Pot. Iodidi, gr. iij. 

Liq. Potassse, tt^ • xxiv. 
Sp. iEth. nit. 3 j. 

Decoct. Sarsoe. co. q. s. ; to make a three ounce mixture. 
A table-spoonful of this may be given three times a-day to a child of three years old. 

24 



370 ENGLISH CHOLERA — DYSENTERY. 

table astringents, and the aromatic confection may be administered 
(F. 69) * 

It sometimes happens that the disease assumes a more severe 
character ; the vomiting and purging being profuse, and much tinged 
with bile, are supposed by some to consist mainly of that secretion, 
though there can be little doubt that it is largely diluted, as well by the 
exhalations from the alimentary canal as by a great flow of mucous 
from the biliary passages. With the purgings are violent pains in 
the stomach and bowels, cramps in the abdominal muscles and in the 
legs, depression and tendency to collapse, with cold extremities and 
a feeble pulse. The exhaustion and collapse has sometimes been so 
great that death from syncope has ensued. This is the English 
cholera, or sporadic cholera, generally more or less prevalent in the 
autumnal months; but differing widely from the fatal epidemic, or 
Asiatic cholera, from which it may be distinguished by the evacua- 
tion being coloured, the urine not being suppressed, the tongue being 
warm, and, by the face and extremities, though showing signs of 
depressed circulation, not presenting the leaden colour and sodden 
feel of that fearful malady. 

The prognosis of the cholera of this country is upon the whole 
favourable, though persons of feeble powers sometimes give way 
under it. . 

At the commencement of this disease, the best treatment is that 
recommended by Sydenham, and which is in principle that which has 
been so much insisted upon throughout this work, namely, the allow- 
ing of the subsidence of the irritation. Any attempt either to expel 
the offending matter by purgatives, as well as that of locking up the 
acrid discharges in the canal, must be injurious. He therefore recom- 
mends emollient drinks ; of these we possess an admirable one in the 
form of arrow-root. 

If, however, the vomiting and diarrhoea continue obstinate, and we 
are rarely called until they have done so for a few hours, the best 
and safest plan is to give an opiate, of which the best form is a grain 
of solid opium with a grain of calomel. This may be repeated in four 
or six hours, or even less if the sickness and vomiting continue. Some 
cretaceous mixture may also be given after every alternate evacua- 
tion (E. 70).f If the extremities become cold and the pulse feeble, 
wine in brandy and ammonia should be given ; and diligent friction 
should be used to the abdomen and extremities, when the cramps are 
distressing. 

Dysentery is essential in an inflammation of the mucous membrane 

* (69) ]*. Confect. Arornat. gr. xv. 
Tiuct. Cinnam. co. gj. 
Infus. Cusparise, gvij. 3M. 
To be repeated twice or thrice a-day. 

f (70) $. Confect. Aurant. gij. 
Vin. Ipecac. 3 ss. 
Tinct. Opii, n^. xx. 
Mist. Cretae, ^ iv. 

Aq. Cinna-n. q. s. ; to make a six ounce mixture, of which one ounce 
is to be given after every alternate evacuation. 



CAUSES AND TREATMENT. 371 

of the large intestines, and its effects are morbid secretions from the 
membrane with excessive irritability of the canal. Consequently we 
have — griping pains in the abdomen, generally referred to the course 
of the large intestine, — excessive straining, and tenesmus, — slimy 
mucous stools, often tinged with blood. The acute form of this dis- 
ease is attended with the fever of mucous inflammation. 

When the inflammation is in the descending colon and rectum, the 
stools are very scanty, and contain little fsecal matter; when, on the 
other hand, it is nearer towards the caecum, there is more liquid fsecal 
matter mingled with the blood and slime ; the disease partakes, in 
fact, more of the character of diarrhoea, and has been termed dysen- 
teric diarrhoea. 

Dysentery is a very severe and often fatal disease in hot climates, 
and is one specially fatal to soldiers exposed to vicissitudes of weather 
in such situations. 

It is by no means so common now in England and the metropolis, 
as in the days of Sydenham, still, the wards of our hospitals present 
cases of acute dysentery, commencing in this country, though the 
majority are severe cases of the chronic disease in persons who have 
under a* one the acute stage abroad. 

The symptoms of fever sometimes precede those of the local affec- 
tion, but more frequently the latter declare themselves the first. The 
fever is, at the commencement, that of active inflammation, but as it 
is also that of mucous inflammation in the abdomen, it soon assumes 
more of an asthenic character, and the pulse becomes compressible. 
Except the fever be great, the tongue may be natural. 

The pain is often severe, though not generally constant, and there 
is usually more or less tenderness along the course of the colon. One 
most distressing symptom is the frequent desire to go to stool, which 
is not relieved by obeying the call. Sometimes the matter discharged 
is white slime, but more frequently it is tinged with blood, constitut- 
ing what used to be commonly termed the bloody flux. Sometimes 
there is dysuria ; and in very severe cases the stomach often sympa- 
thises, and there is vomiting. Whilst these symptoms continue, the 
febrile condition is kept up, and assumes a low typhoid form, and the 
patient may ultimately sink from asthenia. 

The anatomical changes are essentially those of acute inflammation 
of the mucous membrane and sub-mucous areolar tissue, for a descrip- 
tion of which we would refer to the work of Drs. Jones and Sieve- 
king.* The muscular and peritoneal coats are rarely involved; but 
the whole internal surface of the large intestines may be often seen 
to be reduced as it were to a ragged mesh of disorganisation. 

The causes of this severe form of the disease appear to be exposure 
to vicissitudes of heat and cold, and wet, especially in hot climates, 
and in marshy localities. It is sometimes a sequel of ague, and cer- 
tainly infests the same districts. We have already shown how 
dysentery may lead to disease of the liver. But in hot climates 
more particularly, ague gives rise to congestion of the liver, which, 

* "Manual of Pathological Anatomy," Philadelphia edition, p. 494, et seq. 



372 DYSENTERY. 

by obstructing the return of blood through the portal vein from the 
rectum and descending colon, therefore favours hyperemia of those 
parts, and consequently dysentery. The causes of dysentery are 
brought as it were to a focus amongst soldiers engaged in active ser- 
vice, in hot climates and marshv districts, and therefore it has not 
been unaptly called by Sir James M'Gregor, "the scourge of armies." 
Under such circumstances, too, it appear in some instances to have 
assumed a contagious character. 

The prognosis of the dysentery of hot climates must depend much 
on the character of the disease prevailing at the time. In this climate 
it is not often fatal, though it may be so in feeble constitutions, espe- 
cially in children, and in young persons of strumous diathesis, in 
■whom there would appear to be a tendency to scrofulous diseases in 
the abdomen. 

In the severe form of the acute disease, the plan recommended in 
the army has been, bleeding at the commencement, and immediately 
after twelve grains of Dover's powder every hour for three doses; 
diluent drinks are to be freely given, and sweating encouraged for 
eight hours ; afterwards, three grains of calomel and one of opium 
every alternate night, and in the intervening clays two drachms of 
Epsom salts in light broth. The bleeding was repeated if the pulse 
warranted it; Dover's powder given immediately afterwards as a 
sudorific. The above plan embodies the principle of subduing the 
general inflammatory action, and obviating the local irritation. 

When the disease has assumed a more chronic form, in which case 
it has probably proceeded to ulceration, laxatives and opiates should 
be given alternately, and soothing enemata administered. In the 
dysenteries of this country bleeding is rarely required; and when 
the disease presents itself in a severe form there is generally too 
much depression to justify it. 

Leeches may be applied to the track of the colon, if the tenderness 
be great ; or they may be, with much benefit, applied to the verge of 
the anus. Three grains of hyclr. cum cret. may then be given, and 
two hours after that, half an ounce of castor oil, with about three 
minums of tincture of opium. Warm baths, hot fomentations to the 
abdomen, and a few grains of Dover's powder night and morning 
should be employed; and if the disease continue, and the motions 
are pale, about two grains of the hydr. cum cret. may be added to 
Dover's powder. "When the febrile symptoms have subsided, the 
cusparia may be given as an astringent. In the severe forms of 
chronic dysentery, imported from abroad into the wards of our hos- 
pitals, the combination of copper and opium is a most useful astrin- 
gent (F. 71).* 

* (71) R. Cupri Sulphat. gr. ij. 
Opii^gr. iij. 
Ext. Glycrrhiz. q. s. 
Ft. Pil. yj. ; one to be taken three times a-day. 



CHOLERA INFANTUM — SYMTOMS. 37 



Q 



[CHOLEKA INFANTUM. 

This disease, the characteristic symptoms of which are vomiting 
and purging, with rapid and extreme emaciation, is an endemic of all 
the larger cities throughout the middle, southern, and a part of the 
western portions of the United States, during the season of the great- 
est heat. So exclusively is it confined to this portion of the year, as 
to be familiarly denominated in many of our cities, the summer com- 
jjlaint of children. 

The disease is met with only in infants; and it is, perhaps, one of 
the most fatal to which they are liable in this country. This results 
less from the actual malignancy of the disease, than from the con- 
continued action of the endemic cause — a heated and impure atmo- 
sphere — by which the disease is produced, from the influence of 
which, in the majority of instances, it is scarcely possible to effect the 
removal of the infants, either before or after they are attacked. 

Cholera infantum occurs chiefly in children between four and 
twenty months of age — seldom earlier or later. If its second sum- 
mer is passed without an attack, the infant is considered as being in 
little danger from the disease. 

The attack, in most cases, commences with profuse diarrhoea — the 
discharges being sometimes of a green or yellow colour, but more 
commonly colourless, or nearly so, and of a watery consistence, often 
intermixed with minute whitish flocculi. The diarrhoea is very soon 
accompanied by great irritability of stomach, every thing swallowed 
being immediately rejected. In some cases the infant is, from the 
first, attacked with almost incessant vomiting and watery purging ; 
the stools being small in quantity and forcibly expelled. More com- 
monly, however, they are large in quantity and passed without the 
least effort. 

- 'From the very commencement of the attack the child exhibits 
great languor and prostration, and becomes rapidly and extremely 
emaciated. 

In most cases, the pulse is, at first, quick, frequent, small, and 
sometimes tense. The tongue is coated with a white, slimy mucus. 
The skin is unusually dry and harsh. The head and abdomen are 
hot, and the extremities either of their natural temperature, or more 
or less cold. There is intense thirst. Most commonly a degree of 
febrile reaction takes place towards evening. Some degree of abdo- 
minal pain is always experienced, causing the child to be fretful, 
restless, to draw up its knees, and to utter, occasionally, acute screams. 
The pain is more severe in some cases than in others, the abdomen 
being tender to the slightest touch, and more or less tympanitic. 

In many cases the extreme irritability of the stomach soon ceases, 
the diarrhoea, however, continuing unabated, or the evacuations from 
the bowels increase in frequency but diminish in quantity. The 
irritability of the intestinal canal is often such as to cause whatever 



374 CHOLERA INFANTUM. 

is taken into the stomach to be immediately discharged per anum, 
without having undergone the slightest change. 

Delirium occasionally sets in at an early period of the attack. The 
eyes of the patient become wild and injected — he tosses, incessantly, 
his head backwards and forwards, and frequently attempts to bite or 
scratch his attendants. 

Although, in very violent cases, death, from extreme prostration, 
may occur within twenty -four or forty-eight hours, the disease usually 
runs a protracted course. The child becomes more and more emaci- 
ated — the skin cool and clammy, shrivelled, and of a dark brownish 
hue. It is often covered with minute petechias. The eyes are lan- 
guid, glassy, and hollow, the countenance shrunken, the nose sharp 
and pointed, the lips thin, dry and shrivelled. The fauces becoming 
dry, a difficulty in deglutition is experienced, and the child is induced 
to thrust his hand deep into his mouth as if to remove some offend- 
ing substance. The abdomen becomes more and more distended, 
and the hands and feet pallid, or of a leaden hue, and oedematous. 

The discharges from the bowels become dark coloured, and very 
offensive — resembling the washings of spoiled meat — or they are com- 
posed entirely of a small quantity of dark coloured mucus, mixed 
with food or drinks that have been taken into the stomach. 

The patient becomes more and more exhausted — rolls its head 
about when awake, and utters constant short, plaintive, scarcely 
audible cries; or, he lies constantly in a state of partial stupor, with 
half closed eyelids, and so insensible to external impressions as to 
allow flies to alight on the half exposed eyeballs without his exhibit- 
ing the slightest consciousness of their presence. 

In the majority of the protracted cases, an eruption of very minute 
white vesicles occurs upon the breast and upper portion of the abdo- 
men. 

Frequently the brain becomes affected at an early period of the 
attack, and the patient dies with all the symptoms of acute hydro- 
cephalus. More commonly, however, he falls very gradually into a 
state of complete coma, death being not unfrequently preceded by 
convulsions. 

The pathological lesions in this disease vary according to the 
period at which death takes place. When this occurs early in the 
attack, often the only morbid appearance to be detected is an extreme 
paleness of the mucous coat of the stomach and intestines, with more 
or less congestion of the liver. Where the disease has lasted for a 
longer period, increased redness in points or patches of the alimentary 
mucous membrane, is generally present. 

The red points have, in most cases, the appearance of minute 
extravasations of blood. They are sometimes isolated and spread 
over a large portion of the stomach and duodenum, or occur only in 
the small intestines. In other parts of the bowels they occur in 
patches, often slightly elevated, from a thickening of the mucous 
membrane. The patches vary in size, but are never very large. In 
other cases, with increased redness of some portions of the intestines, 
there is an extreme contraction of their caliber. Occasionally more 



9' 



CAUSES — PROGNOSIS. 61 O 

or less softening of some portions of the mucous membrane of the 
stomach or intestines is met with, often unattended with the slightest 
trace of inflammation. The muciparous follicles of the intestines are 
in most instances enlarged, often inflameu, and occasionally ulcerated. 
The liver is very commonly enlarged, and more or less congested ; 
the gall-bladder filled with dark green bile, or with a pale almost 
colourless fluid. 

In perhaps the majority of the more protracted cases, serous effu- 
sion is found upon the surface, at the base, or in the ventricles of 
the brain, accompanied, in some instances, with opacity and thicken- 
ing of the arachnoid membrane. In very protracted cases, softening 
of the brain, to a greater or less extent, is often present. 

Cholera infantum would appear to depend upon hyperemia of the 
mucous membrane of the alimentary canal, with a morbidly increased 
activity of function in its muciparous follicles — more or less inflam- 
mation being excited, in the course of the disease, either by the con- 
tinued action of the causes by which it was originally produced, or 
by accidental sources of irritation. 

The disease is the result exclusively of a heated, confined, and 
impure atmosphere. This acts primarily upon the skin and second- 
arily upon the mucous membrane of the digestive canal, at a period 
of life, when from the process of dentition, and the development and 
activity of its muciparous follicles, the membrane is strongly predis- 
posed to take on morbid action. 

The prevalence of cholera infantum is always in proportion to the 
heat of the summer, with which it sets in and declines. It is, also, 
in a great measure confined to the larger and more crowded cities of 
the middle and southern states ; and in these is chiefly prevalent and - 
fatal among the children of those who inhabit small, ill- constructed 
houses, located in narrow, confined lanes, courts, and alleys, over- 
crowded in population, or in situations abounding with filth. When 
it occurs in the country, which it seldom does, it is always in low, 
damp, and otherwise unhealthy localities. 

The process of dentition may be considered as among the most 
common predisposing, and errors in diet as a frequent exciting cause 
of the disease. 

The prognosis in cholera infantum will, in a great measure, depend 
upon the possibility of removing the patient from the influence of 
the endemic cause by which the disease has been produced and kept 
up, and the period of the attack at which such removal is effected. 
Without such removal it is very difficult in any instance to effect a per- 
manent cure, while in most cases, in the early stages of the disease, little 
else is required ; even at a later period, its effects are always salutary, 
and has enabled the physician, by an appropriate treatment, to effect 
a cure under circumstances apparently the most unpromising. Even 
when a removal to a more airy and healthy situation cannot be 
effected, much benefit will be derived from carrying the patient 
frequently into the open air, in the nearest open and healthy situa- 
tion, in a carriage, or in the arms; daily rides into the country are 
always of advantage; and still more so, when the patient resides in 



376 CHOLEEA INFANTUM. 

the vicinity of a large river, daily trips upon the water in an open 
boat. 

When in doors, the patient should occupy, both day and night, as 
large and airy a room as can be commanded, and this should be kept 
strictly clean, dry, and freely ventilated. His clothing should always 
be dry, clean, and while sufficient to guard from any sudden change 
in the temperature of the air, not too warm or heavy so as to overheat 
him. Fine soft flannel, or soft coarse muslin next the skin, will be 
adviseable in nearly every instance. The patient should sleep upon 
a mattress, or on a folded blanket, laid upon the sacking bottom or 
the floor of his crib, his body being defended by a light, loose covering. 

In all cases in which a child is attacked with the symptoms of 
cholera infantum, the gums should be at once examined, and if they 
be found hot, swollen or inflamed, they should be freely divided. 
The patient should be confined exclusively to the breast, or if 
weaned, to a diet of tapioca, pure arrow-root, or rice flour with milk, 
or plain beef, mutton, or chicken broth ; and for drink, cold water 
in small portions at a time, gum water, or gum water with a slight 
addition of rennet whey ; he should be immersed daily in a bath, 
warm or tepid, according as the temperature of the skin is deficient 
or increased, followed by frictions over the entire surface of the 
body with the hand or a soft dry cloth. 

These measures, with exposure to a pure, free atmosphere, will 
very generally, when commenced with at the onset of the attack, 
speedily arrest it. 

Should the diarrhoea, however, continue to be troublesome, one- 
sixth of a grain of calomel, in combination with a-half grain of ace- 
tate of lead, and three or four grains of prepared chalk, repeated 
every three hours, will ordinarily suspend it. 

To allay the irritability of the stomach which is so commonly pre- 
sent in the commencement of the attack, from a sixth to an eighth of 
a grain of calomel, rubbed up with a little dry sugar, and sprinkled 
upon the tongue, will in general succeed ; if not, a drop or two of 
spirits of turpentine, or a solution of camphor in sulphuric sether, or 
a drop of creasote diffused in water may be tried. The acetate of 
lead in solution will often promptly allay the irritation of the stom- 
ach when everything else fails. Five grains of the acetate of lead, 
with the addition of five drops of diluted acetic acid, may be dis- 
solved in two ounces of pure water, and sweetened with a drachm of 
refined sugar, of which a teaspoonful may be given every hour until 
the vomiting ceases. When the vomiting is violent and frequent, 
the application of a few leeches to the epigastrium will be found ser- 
viceable. 

In cases attended with pain, tenderness and tumefaction, with 
increased heat of the abdomen, leeches, in numbers proportioned to 
the age of the patient should be applied to the epigastrium, and fol- 
lowed by light emollient cataplasms or warm fomentations over the 
whole abdomen. The sixth of a grain of calomel rubbed up with 
two or three grains of prepared chalk and a third of a grain of 
hyoscyamus may be given every three hours. 



TREATMENT. 877 

When symptoms of cerebral irritation present themselves — heat of 
the head, a wild injected state of the eyes, aversion from light, deli- 
rium, &c. — leeches are to be applied to the temples or behind the 
ears, cold lotions to the scalp, and some rubefacient embrocation to 
the lower extremities, or warm sinapised pecliluvia employed. In 
all cases in which there is a tendency to disease of the brain, small 
blisters behind the ears, kept open by some stimulating dressing, 
will be found of advantage. 

When, after the morbid irritability of the stomach has subsided, 
frequent thin watery discharges from the bowels still continue, one 
of the best prescriptions will be found to be a combination of calomel, 
one-fourth of a grain, prepared chalk three grains, acetate of lead 
one grain, and extract of hyoscyamus one-third of a grain ; to be 
repeated every three hours. As soon as the discharges from the 
bowels have become diminished in frequency, and more consistent in 
form, the common chalk mixture, with the addition of some light 
vegetable astringent, will generally confirm the cure. 

In the more chronic stage of the disease, anodyne injections com- 
posed of thin starch with the addition of a few drops of the tincture 
of opium, the administration by the mouth of some astringent as 
kino, decoction of dewberry root or the geranium maculatum, tinc- 
ture of galls, or tannin, with a well regulated diet, and exposure to a 
dry, cool, and pure atmosphere, will often effect the removal of the 
disease, under the most unpromising circumstances. The tartrate of 
iron in solution, or the persesquinitrate of iron will in these cases be 
often found beneficial. The sulphate of quinia in solution, with the 
addition of tannin, besides exerting a favourable impression upon the 
disordered condition of the bowels will, in many cases, at the same 
time, accelerate the patient's recovery by restoring strength to the 
system generally. 

In cases attended with thin, dark coloured, highly offensive dis- 
charges from the bowels, frequent griping pains, and a tympanitic con- 
dition of the abdomen, the best effects will be derived from the use 
of the following mixture: B. Mucil. g. acacias, E iij- ; Sach. alb. pur. 
Z iij.; Spir. terebinth. 3 ij.; Magnes. calc. gr. xv. Tinct. opii camph. 
E ij. M. Dose, a teaspoonfull every three or four hours. When 
there is great irritability of the bowels, 3 iij. of the tinct. kino or 
catechu may be advantageously added. Under the same circum- 
stances, pulverised charcoal will often be found to correct very 
promptly the morbid condition of the stools. It may be given in 
the following combination: R. Carb. ligni, 3 j. ad. 5 ij.; Pulv. rhei, 
9 ij.; Ipecac, pulv. gr. iij.; Ext. hyoscj^am. gr. iv. M. f. chart., No. 
xii. ; one to be given every three or four hours. 

After the stomach and bowels have resumed their natural condi- 
tion, the utmost care must be taken to prevent a relapse, by a proper 
regulation of the child's diet and clothing, and its exposure to a cool, 
free, and otherwise healthy atmosphere. — Editor.] 



378 DISEASES OF THE KIDNEYS. 



XXII. 
DISEASES OF THE KIDJSTEYS. 

The urinary diseases which more particularly belong to the pro- 
vince of the physician are in general those in which the secretion of 
the kidneys deviates from its healthy condition, either as to quantity 
or quality ; independently of those mechanical causes which interfere 
with its excretion from the bladder, the management of which falls 
more within the province of the surgeon. Now it must be borne in 
mind that for the secretion of healthy urine two general conditions 
are essential. First, there must be a healthy and normal condition 
of the blood from which the secretion is to be eliminated, and 
secondly, a healthy condition of the kidneys which are to eliminate 
it. 

As regards the quantity of the urine, we have elsewhere explained 
the law, that in order to the due supply of water (upon which the 
quantity of the urine depends) there must be a ready absorption from 
the stomach and intestines through their respective veins, a free pas- 
sage through the portal vein and its branches in the liver, a free return 
through the venas cavas hepaticas to the ascending cava and right 
auricle and ventricle, a free passage through the pulmonic circulation 
to the left auricle, a free transit through the mitral valve and left 
ventricle, and thence through the aorta and renal arteries to the 
kidneys, and through these organs ; and if obstruction to the circula- 
tion exist in any part of this circuit, we shall have the quantity of 
urine defective : and very scanty urine means nothing more than 
this ; it points out that there is this cause somewhere, but it does not 
necessarily imply that there is mechanical obstruction ; for, on the 
contrary it may arise altogether from a morbid impediment to some 
of those physiological actions which are essential to its transit through 
this course. 

When there is sickness, the fluid taken into the stomach being 
rejected before any absorption can take place, the urine is scanty, 
and the same is true when there is obstruction in the course of the 
small intestines. If, again, there be congestion or induration of the 
liver, the same result will ensue, and also if the fluid pass very rapidly 
through the intestines, as in severe diarrhoea, and still more when, 
instead of absorption, there is very rapid exhalation of fluid into the 
stomach and small intestines, as in the case of cholera, in the severest 
forms of which there is absolutely no urine secreted. When, again, 
there is obstructive disease about the right side of the heart, or in 
the cava near the entrance into the right auricle, and in the still 
more common case of obstruction to the pulmonic circulation from 
disease of the bronchial tubes or lungs ; or, if there be disease of the 
mitral valve, causing either obstruction or regurgitation, the urine 
will be scanty ; and also when there has been disease of the aorta or 



CHANGES IN THE URINE. 379 

its sigmoid valves of sufficiently long standing to impede the action 
of the left ventricle. We see then that the urine may be diminished 
in quantity from disease in any of these situations, independently of 
any affection of the kidneys themselves. 

With the kidneys the case is somewhat different. There may be 
disease of these organs without any diminution in the quantity of 
the urine, or even with an increased flow of it. In those diseases 
again which interfere with the capillary circulation throughout the 
system, in fever, for instance, the urine is scanty. Thus, if there be 
a free elimination of water by the malpighian bodies, the quantity of 
the urine will not be diminished, though the tubes may be diseased, 
provided that the disease be not such as to cause any mechanical 
impediment to the passage of fluid through them, in which case the 
change will be not in the quantity, but in the quality of the secre- 
tion ; but if the disease be such as to cause thickening or other 
obstruction of these tubes, or strangulation or disorganisation of the 
malpighian tufts, the secretion of urine will be impeded. 

As regards the changes in the quality of the urine, we may divide 
them into two great classes. I. Those in which the deviations from 
the healthy condition consist — of matters belonging to it in health, 
but altered in quantity, — or of substances which are not integrant 
ingredients of healthy urine, but are products of imperfect assimila- 
tion or digestion ; so that here we have two kinds of abnormal urine 
depending not so much upon the disease in the secreting organs as 
upon a morbid condition of the blood from which the secretion is to 
be derived ; of these, as they belong rather to lesion of the organs of 
digestion and assimilation, we shall speak elsewhere. II. As regards 
the other class of morbid products in urine, those mainly in which 
the integrant ingredients of the blood are present, we find that unless 
they proceed from lesion of the urinary passages or bladder, they are 
the effect either of passive haemorrhage or of that large and impor- 
tant class of diseases which, for convenience sake as much as from 
the want of a better term by which to express them, we include 
under the name of Bright's disease, after the illustrious physician 
to whose researches we are indebted for nearly all the knowledge 
we possess respecting them. In this form of abnormal urine we find 
two remarkable conditions, both of primary importance in the clini- 
cal history of the disease of which we are treating : (1) The presence 
of some of the essential ingredients of the blood ; and (2) the abscence 
or defect of the natural ingredients of the urine. 

(1.) The presence of blood-matter in the urine is, when it proceeds 
from the kidneys, a product of diseased action in those organs, and 
is to be received as probable evidence of such : but as that action is 
generally of an inflammatory character (acute, subacute, or chronic), 
it, like similar disease in other organs, interferes with their natural 
and healthy functions ; that is to say, in this case, with the elimina- 
tion of those substances which ought to be carried out of the system 
by the kidneys— hence (2) the absence or defect of the natural solid 
contents of the urine. Some of these, the urea and uric acid more 
particularly, act as poisons when retained in the system, and exert 



380 DISEASES OF THE KIDNEYS. 

their influence either directly upon the nervous centres, or more 
indirectly and slowly by producing inflammation or chronic changes 
in the various tissues of the body ; and further than this, the very 
abstraction of the blood-matter by the urine is itself a direct source 
of mischief, producing, when long continued, a deficiency in the 
natural elements of that fluid, which is the pabulum of the whole 
system. 

Of the ingredients of the blood, as in the original healthy blood, 
so also in the morbid secretion, which is derived from it, the albu- 
men is the most abundant of the soluble solid contents. The insolu- 
ble or red globules, though the most abundant in the blood, are not 
necessarily present in the albuminous urine, since, owing to their 
inability to transude through the coats of the vessels, they can only 
find their way into the urine by more or less laceration of some of 
the minuter vessels. Indeed, as a general rule, we may say that the 
red globules, when present in this form of the morbid urine, are 
never so in a quantity proportionate (as compared to the blood) to 
the albumen, and that when present in the urine in such quantity, 
they indicate that the affection is more strictly of a hemorrhagic 
character, probably of a traumatic origin. 

As then the albumen is the prominent ingredient in such exuda- 
tion, it is important to be provided with a ready test for detecting 
its presence. Now it is well known that a simple solution of albu- 
men in pure water is rendered milky by the application of heat 
above 160° F., owing to the coagulation of the albumen at this 
temperature ; but the urine not being a simple fluid, but one which 
may contain substances which prevent this coagulation, such as the 
alkalies and alkaline carbonates, which form with it albuminates 
soluble in boiling water, we have need of some other test not liable 
to this objection. Nitric acid is such a test, as it will throw down 
albumen when present even in a minute quantity, and of course pre- 
vents its combining with the alkalies. But nitric acid may throw 
down from the urine a precipitate which is not albumen; thus if 
there be a large quantity of urate of ammonia present, the nitric acid 
combines with the latter, and separates the uric acid, which gives to 
the urine a turbidity that by an unpractised eye is not very readily 
distinguished from albumen ; this, however, is re-dissolved by heat. 
Heat is also liable to the objection, that it may produce a precipitate, 
which is not albumen : this ensues when the urine contains a large 
quantity of phosphates : such urine is generally alkaline, but not 
necessarily so ; this precipitate, when it occurs, is immediately re-dis- 
solved by nitric acid. We see then that nitric acid and heat may 
both give precipitates which are not albumen, but that the precipitate 
which is thrown down by heat is re-dissolved by nitric acid if it be 
not albumen ; and similarly that by nitric acid disappears by heat. 
Heat again is liable to the objection that it may give no precipitate 
though albumen be present : to this objection nitric acid is scarcely 
ever liable, though the addition of a few drops may give a precipi- 
tate, which is re-dissolved by a further addition, and this may even 
take place a second time if the acid be added guttatim ; but the fur- 



TESTS FOR ALBUMEN" IN THE URINE. 381 

ther addition of acid produces a precipitate which neither itself nor 
the heat can re-dissolve. 

The two tests thus used in conjunction are therefore liable to little 
or no fallacy : the nitric acid alone is no doubt nearly sufficient for 
all cases ; but if the urine be previously turbid by any of those sub- 
stances which are re-dissolved by heat, we cannot so well judge of 
the effect produced by acid. This difficulty would no doubt be 
obviated by previously filtering the urine, which ought to be done 
in every doubtful case. For bedside purposes the best method is to 
put first a small quantity, say about three drachms, into a clean test- 
tube, and if the urine be previously clear, and no precipitate comes 
down with nitric acid, there is, in all probability, no albumen present; 
but should any appear, boil the fluid in the tube over a spirit-lamp, 
and if this resist the heat, we may be sure that it is albumen. Should, 
however, no precipitate occur upon the addition of the acid, we may 
be almost equally sure that there is no albumen ; but as it is well to 
verify even this test, let some of the urine be boiled in a clean tube, 
and then add the acid ; if no precipitate occurs with either test, we 
may be nearly confident that there is no albumen, and if heat gives 
one which is re-dissolved by nitric acid it is phosphatic, and if there 
be none by heat, but nitric acid gives one, it is ablumen, as it comes 
down in the heated urine. 

It is commonly supposed that the phosphatic precipitate first takes 
place only in alkaline urine ; this, however, is by no means univer- 
sally true, as has been shown by Dr. Eees: such urine, however, 
generally has a less decidedly acid reaction than healthy urine, or 
even the majority of cases of albuminous urine. It is remarkable 
that the liability to the opposite fallacy, namely, the presence of 
albumen without its giving a precipitate by heat, is also connected 
with alkaline urine; and, universally, when the urine is alkaline we 
are not to suppose that it is not albuminous because heat gives no 
precipitate, or rather we should place no reliance at all upon heat 
under such circumstances. It is not, however, as certainly true that 
when the urine is acid, albumen, if present, will be thrown down by 
heat, since specimens of acid urine have been examined, though 
rarely, (and in carefully-cleaned tubes, too,) in which there has been 
no precipitate thrown down, although the heat has been continued 
for some time. Such urine has generally been of high specific 
gravity, and it is therefore probable that the albumen has been held 
in solution, by the ammonia resulting from the decomposition of the 
urea. It follows from this that heat is never to be used without first 
ascertaining whether the urine is acid or alkaline, an examination 
which ought, under no circumstances to be omitted. For bedside 
purposes in private practice, and upon a first visit to a patient, when 
other tests may not be so readily procured, heat applied in the rough 
way of a spoon over a candle is a very convenient one, and a practised 
eye will generally recognise with tolerable certainty a precipitate of 
albumen thrown down in this way : but this should never preclude a 
more careful examination afterwards; and when there are other 
symptoms which indicate the probability of the urine being alba- 



382 DISEASES OF THE KIDNEYS. 

urinous, the absence of a precipitate by this test is never to be con- 
sidered as satisfactory. The fallibility of heat as a test for the 
presence of albumen, both positive and negative, probably accounts 
for the fables narrated of persons passing albuminous urine after a 
hearty meal of animal food, and when suffering under dyspeptic 
symptoms, produced by indigestible substances; such, for instance, 
as pastry. With regard to the latter, it must be remembered too 
that disordered stomach is one of the effects of renal disease, and may 
be present when many of the more prominent ones are wanting. 
Persons under the influence of mercury are also said to pass albu- 
minous urine without there being disease of the kidney ; but as far 
as may be inferred from a very large number of observations made 
at Guy's Hospital, this is also an erroneous belief, though several 
such patients passed urine which gave the phosphatic precipitate 
with heat. Pregnant females not unfrequently pass albuminous urine, 
the albumen, in most cases, disappearing after delivery, and the patients 
doing well ; but, as has been pointed out by Dr. Lever, care is re- 
quired in such cases, as there is a greater liability to puerperal con- 
vulsions, and other formidable nervine symptoms. 

A very delicate test for albumen is the addition of a solution of 
ferro-cyanide of potassium after acidulating the urine with a few 
drops of strong acetic acid. 

The methods of testing the urine for the presence of albumen have 
been dwelt upon at more length on account of their extreme import- 
ance, and the presence of albumen being the readiest test of the 
elimination of blood-matter by the kidneys. When albumen is 
present, fibrine is so also, though it may escape detection ; in most 
cases, however, it may be preceived in the urine, by the aid of the 
microscope, in the form of casts of the uriniferous tubes. Blood-cor- 
puscles may or may not be present ; when they are they may be de- 
tected by the microscope, and their presence in great abundance is a 
sign of the disease being rather of a hasmorrhagic character than the 
renal disease which we are now considering. Hseniatosine or hsemato- 
giobuline may find its way into the urine without any laceration of 
the vessels, by the disintegration of the corpuscles. It may be ob- 
served, however, in reference to this, that purpurine has often given 
to urine an appearance that has led even medical practitioners of 
experience to a belief that blood was present. 

When pus is present in the urine, its serum will of course render 
the latter albuminous ; the pus will, however, be detected by the 
appearance of the pus- corpuscles under microscopic examination, as 
well as by the action of liquor-potassse applied to the sediment which 
subsides from the urine. Puriform urine is, however, by no means 
incompatible with Bright's disease. 

We now proceed to speak of that large class of diseases with which 
albuminous urine is commonly associated, though it may not be 
present in all cases; and we commence with acute nephritis as essen- 
tially belonging to it, though, perhaps, not always included in the 
term Bright's disease ; since the profession were not unacquainted 
with it before the appearance of the works of that physician, though 



NEPHRITIS. 383 

for a more rational knowledge of its pathology we are mainly in- 
debted to him and his followers. 



NEPHKITIS. 

Although the kidneys, like other organs of the body, are liable 
both to acute and chronic inflammation, of which the latter is incom- 
parably the more common, yet, as these, since the investigation of 
Dr. Bright, have generally been included under the term Bright's 
disease, we will, for the sake of convenience, restrict the term 
nephritis to the acute inflammation of the kidneys. 

By nephritis, then, we mean an acute inflammation of the kidney, 
which may be either idiopathic, or it may be the effect of some 
mechanical cause, as the presence of a calculus, or of some poison 
taken into the stomach, and thence absorbed into the circulation : of 
this we have instances in the effect of very powerful diuretics, and 
also of acute poisoning by lead ; tubercles, or the presence of strum- 
ous, or sometimes of fibrinous deposits, may also be either the causes 
or predisponents of inflammations. In the idiopathic inflammation, 
the kidney is generally somewhat enlarged, of a deep dusky red or 
chocolate colour throughout, and, when handled, softer and more 
lacerable than natural ; in severe and fatal cases of this kind we often 
find minute points of suppuration through the organ, and puriform 
mucus oozing from the points of the infundibula. This inflammation 
may probably terminate by resolution, in which case the symptoms 
subside, though in a large proportion of cases it proves fatal in its 
acute or earlier stage ; or, it may lead to suppuration, one or more 
abscesses being formed in the organ, or sometimes the kidney is 
reduced to a mere sac of puriform matter. Acute nephritis may also 
pass into a chronic state, constituting one of the forms of Bright's 
disease. 

The diagnosis of nephritis is not without its difficulties, and the 
same remark applies to other forms of renal irritation. Gastritis has 
many symptoms of nephritis ; indeed sickness belongs as much to 
the latter as the former, and in both is the urine excessively scanty ; 
but besides the unfrequency of pure gastritis, the urine when passed, 
though concentrated, is otherwise healthy, and contains no blood- 
matter ; whereas, in nephritis what little is excreted generally con- 
tains albumen. With regard to another affection however, namely, 
obstruction in the duodenum or upper part of the small intestines, 
the distinction is still more difficult, since, as in that case we may 
have no urine at all for three or four days, we can get no evidence 
from that source: this long-continued suppression should, however, 
incline us to look for its source rather in the intestines than in the 
kidneys. In this case, as also in that of the stomach, we must direct 
our attention to the seat and character of the pain; its lancinating 
character, its extension along the course of the ureters and down the 
thigh, or the numbness in the latter situation, together with retraction 
of the testicle, all indicate nephritic affection; but, on the other hand 



384 DIAGNOSIS OF NEPHRITIS. 

these may be wanting, and it is not impossible that in occlusion of 
the duodenum, there may be spasms and cramps which may simulate 
the pain in the thigh and be attended with retraction of the testicle : 
this difficulty, it is true, is not a common one, but speaking from 
personal experience, it has occurred in several instances, and it has 
been a great difficulty when it has done so, though it does not seem 
to have attracted the attention of authors generally ; it is, however, 
more readily solved, when the connection between intestinal obstruc- 
tion and scanty urine is remembered and understood. In colic the 
pain will often be apparently in the region of the kidneys or ureters, 
or both ; but in that disease, owing to the obstruction being low in 
the bowels, the urine is abundant. This will prove that the disease 
is not nephritis, though it will not prove that the pains do not 
proceed from the presence of a calculus : but to that we shall pre- 
sently revert. In connection with the diagnosis of this disease, we 
may mention, that the testicle may not only be retracted and painful, 
but that it may also be actually inflamed ; this fact, pointed out by 
Dr. Watson, in connection with nephritis, though it may not often 
afford much aid to our diagnosis, is most interesting as an instance 
of inflammation arising from irritation at one extremity of a nerve 
causing irritation or inflammation at other extremities of the same, or 
communicating nerves: in other words, it is evidence of the reality 
of nervine inflammation. 

We have just been alluding to the irritation arising from a cal- 
culus, and this may often be attended with nephritis ; indeed it is, 
perhaps, the most frequent cause of the acute form of that disease : 
but these pains may arise without inflammation, or with inflamma- 
tion confined to one kidney only; in the former case the disease is 
described as nephralgia, (some practitioners indeed speak of nephral- 
gia as an independent disease). In nephralgia the local symptoms 
are the same as in nephritis, but there is no fever; there will, how- 
ever, be sickness, and the urine may be abundant, or even excessive : 
it is here then, perhaps, that the greatest difficulty will arise in dis- 
tinguishing this disease from colic; but the lower bowels are not 
obstinately constipated, and the examination of the urine will, in the 
case of a uric-acid calculus, soon settle the question. In the case of 
an oxalate-of-lime calculus, the obscurity is greater, and can be de- 
cided only by a careful microscopic examination of the urine. Still 
it would be possible to multiply cases in which there has existed the 
greatest difficulty in distinguishing between diseases of the colon and 
irritation of the ureter, and the diagnosis is one that can be made 
only by minute investigation of such individual case, and of which 
it is impossible to inclade the whole details under any general rules. 
There is sometimes difficulty in distinguishing disease of the kidneys, 
whether nephritis or neuralgia, from that of the spinal column or the 
contents of the spinal canal. It is true, indeed, that both are often 
implicated at the same time, especially in the cases of suppurative 
disease of the kidney, described by Mr. Stanley ; but in these cases 
the active nephritic symptoms are not generally present, and when 
the vertebraa are diseased, examination of the spinous processes will 



TREATMENT. 385 

almost always detect either tenderness or laxation. The most valuable 
diagnostic sign in such cases is sickness : when the pain proceeds from 
irritation of the kidney, it will rarely be wanting. 

The treatment of nephritis is in principle the same as that of all 
inflammations. We must endeavour to reduce the inflammatory 
action by such general antiphlogistic measures as the strength of the 
patient will tolerate ; next we must use all means to exclude every 
cause of fresh excitement of the inflamed organ, and in very severe 
cases, and where the pulse and general condition of the patient war- 
rant it, blood may be drawn from the arm. In the majority of cases, 
however, cupping from the loins is to be preferred, the quantity 
being of course regulated by the age and general condition of the 
patient. Even where the powers are feeble we may take two or four 
ounces partly as a revulsive. As regards internal remedies we are 
somewhat at a loss, owing to the frequency of sickness. Calomel in 
small doses, in combination with opium, also in small doses, will some- 
times obviate this, but large quantities of mercury are uncalled for, 
and it is very probable that could we bring the system under its 
influence we should promote organic change in the kidneys. Opium 
also must be used with care, both on account of its tendency at first 
to confine the bowels, and the danger of its affecting the brain, already 
threatened by a narcotic poison. Diuretics, though sometimes sup- 
posed to be indicated by the diminished secretion of urine, are the 
most mischievous drugs that can be employed in acute nephritis. 
Antimony appears to be indicated as promoting the action of the 
skin, and thereby determining from the kidneys, instead of to them, 
like diuretics. The objection to its use is the tendency to sick- 
ness; it will not, however, be generally found that minute doses 
of antimonial medicines will aggravate sickness (they may indeed 
stop it), and the following pill will generally be admissible 
(F. 72).* Should the opium be contraindicated by tendency to 
stupor or other form of cerebral affection, or should the tartar 
emetic appear to increase the sickness, we may use a combination of 
henbane with true James' powder (F. 73).f Saline medicines which. 
do not act principally upon the kidneys, such as Liq. amnion, acet. 
and Liq. ammon. citrat., may be employed in small doses, and the 
action of the skin encouraged by large poultices to the loins, and by 
vapour-baths. If sickness be urgent, a few grains of calcined mag- 
nesia may be given in water. The diet should also be strictly anti- 
phlogistic, the aliment consisting mainly or entirely of farinaceous 
substances; animal broths being not only too stimulating to the 
system generally, but objectionable as solutions of azotised matter, 
the natural outlet for such substances being the kidneys, and there- 

* (72) R. Hydrarg. Chlorid. gr. ii. 
Opii, gr. i. 

Antim. Pot. Tart. gr. ss. 
Ft. Pil. vj. ; one to be taken every three or four hours. 

i* 

f (73) $. Pulv. Jacobi veri, gr. iv. 
Ext. Hyoscyam. gr. v. 
Ft. Pil. ij. 

25 



3S6 beight's disease. 

fore such substances being in some degree stimulants to those organs 
Jellies, though not required in more acute stages, are not liable to the 
latter objection, which is however applicable to tea and coffee. It is 
needless to insist upon the necessity for perfect rest in acute nephritis, 
as the patient is generally far too ill to wish to do otherwise than 
keep his bed; still it is a principle to be remembered in the treat- 
ment of the less acute stages, and also as bearing upon the manage- 
ment of kidney disease in general. 

In those cases in which there is no fever, or which are in fact 
nephralgia from the presence of calculous matter, opium may be 
freely used ; and in such instances there will be less danger from its 
effect upon the brain, as the urine is commonly abundant, one kidney 
only being in the majority of cases implicated, or that being, for 
the time at least, sufficient for the purposes of depuration. Under 
such circumstances, too, gentle diuretics may also be sometimes 
used, with a view of aiding the expulsion of the calculus from the 
pelvis of the kidney. For this purpose the citrate of ammonia with 
the potassio-tartrate of soda, in doses of about a scruple, with tinc- 
ture of hyoscyamus, warm-baths and poultice to the loins, will also 
give relief, as will also belladonna liniment or a bellatlonna plaster. 



BEIGHT'S DISEASE. 

We now proceed to the consideration of that class of diseases far 
more common than the acute nephritis, and which produce a very 
large proportion of the deaths arising from chronic disease. If all 
the fatal cases of heart disease and disease of the brain, originating 
from albuminuria, or Bright's disease, be taken fairly into the 
account, it will be found that this disease is second only to phthisis 
in the number of lives which it destroys. The anatomical changes 
which occur in the kidney are almost as various as those which take 
place in the respiratory organs as sequelae of the different forms of 
inflammation, acute and chronic ; or they may be still more aptly 
but less familiarly compared to those which occur in the liver, in 
which we find congestive inflammation of the ducts or catarrhal 
inflammation, cirrhosis or inflammation, of the areolar tissue, with 
contraction, and fatty degeneration. Into the minute changes which 
constitute the varieties of Bright's kidney it is not our province 
very fully to enter, not because those changes are in themselves 
devoid of interest in a practical point of view, but because their 
description, belonging more to pathological anatomy, would refer 
the reader to the Pathological Anatomy of Doctors Jones and Sieve- 
king, p. 547 et seq. Philadelphia Edition. 

For practical purposes we would recognise six forms of Bright's 
kidney, though it is probable that the first three may be different 
stages of the same affection. 

1. That which commonly occurs in an acute form, and which has 
the nearest resemblance to an acute catarrhal affection : it is, in fact, 
if the expression may be used, a bronchitis of the kidney. Like 



ITS DIFFERENT FORMS. 387 

analogous disease in other organs, it evinces the close sympathy 
between the skin and the internal mncous membranes, being that 
form which is generally induced by affections of the skin or impres- 
sions npon it, as in scarlatina and the application of cold to the ex- 
ternal surface. The kidneys are large, swollen in fact, and dark 
from an increased quantity of blood, the tubes being in a condition 
of active hyperemia ; the anatomical changes are very similar in 
appearance to those produced by the passive hyperemia from mecha- 
nical obstruction, forming the " coarse" kidney to be hereafter 
noticed. This form of diseased kidney is perhaps that with the 
pathological anatomy of which we are the least acquainted, since the 
disease is rarely fatal, in this stage at least. In the commencement 
the urine is scanty, of a smoky appearance, as if soot had been stirred 
up in it, and of a specific gravity varying but little from the natural 
standard. It. is highly albuminous, containing also red corpuscles, to 
which its peculiar colour is owing, and epithelial cells, which may 
be seen under the microscope. It is from this circumstance that it 
has obtained the name of acute desquamative nephritis. It is well 
to repeat that the urine is scanty, and that there is, therefore, defec- 
tive depuration of the blood, which is also drained of its solid ingre- 
dients, though not to such an extent as in the next form of the 
disease. 

2. There is the form of disease commonly known as the large 
white kidney, in which the organ is large, generally as much as 
double the natural size and weight. When the tunic is peeled off, 
which it readily may be, the surface is presented, very pale, of a 
polished smoothness, and faintly marked with stellated vessels. The 
section of the organ when cut into presents to the naked eye a dingy 
white surface, almost homogeneous for a considerable depth from 
the surface of the organ, though near the pelvis the straight tubes 
are as strongly marked upon the pale ground. This appearance is 
found, upon microscopic examination, to be produced from the obli- 
teration of the tubuli by inflammatory deposit. Associated with this 
form of disease the urine is nearly about the quantity secreted in 
health, generally of the smoky appearance, noticed in connection with 
the preceding form, from the admixture of red corpuscles, very 
albuminous, and of light specific gravity. As the disease advances, 
the urine commonly becomes less in quantity and of lighter specific 
gravity. The remarkable circumstance in this form of morbid urine 
is the concurrence of a large quantity of blood-matter, and the defi- 
ciency in the proper excretory matter of the urine. 

3. The third form of disease is one which is now become almost 
obsolete amongst pathological anatomists, though it used to be re- 
garded as nearly synonymous with Bright's kidney, namely, the 
mottled, kidney. This is large, and mottled with white upon a 
coarse and rather dark ground ; it is probably a state of transition 
from the first to the second form of the disease. The character of the 
urine secreted by kidneys thus affected is an intermediate one be- 
tween the last two. It is at first of moderate quality and of specific 
gravity of about 1015. It afterwards becomes of lighter specific 



383 bright's disease. 

gravity, and if the case be watched throughout, it first undergoes an 
increase in quantity, and then begins again to diminish: the promi- 
nent characteristics of the urine approaching, as the disease advances, 
more nearly to those of the second form. 

It may here be remarked, that the three forms already described, 
differ probably more in degree than in the nature of the morbid 
change. There is, however, this distinction to be observed, that the 
first form is more commonly an acute affection, and one which has 
therefore a greater tendency to recovery, but which, when fatal, 
proves so in a shorter period, presenting upon inspection the appear- 
ances which have been described ; it may therefore be asked, what is 
the evidence of its being capable of passing into the second ? To 
this it may be replied, that, in those cases, which are not very fre- 
quent, that have commenced with the symptoms characteristic of 
the first form, and which have assumed subsequently a more chronic 
character, and ultimately proved fatal, the kidneys have been found 
to present the appearance of either the second or third. The next 
two varieties which we have to notice are also probably but different 
stages of the same disease, but essentially different from the three 
preceding, though an attempt has been made by Freirick to establish 
the identity of all ; this question has, however, been ably investigated 
and decided in the negative, by Dr. Wilks, in an excellent paper in 
the Guy's Hospital Keports for 1853, vol. viii. p. 232. 

4. The fourth form then is one which differs more in reality than 
in appearance from the second or large white kidney ; the organ 
being, as in that form, " large, dense, and white" (I use the words of 
Dr. Wilks in the paper alluded to above). — " It is, in fact, an entire 
fibrous metamorphosis of the kidney, differing from the latter (form 
2) in this, that whereas the characteristic of that was a diseased con- 
dition of the tubes, which were crowded with exudation, in this, the 
section is smooth, uniform, and evidently consisting of one homoge- 
neous material ; the deposit being in this case in the parenchyma, or 
areolar matrix of the organ, may be regarded in some measure as 
analogous to pneumonic induration. This form of diseased kidney 
is perhaps not of very frequent occurrence, at least, not on the inspec- 
tion table, as it probably passes on to the more frequent and fatal 
form to be next described. As far as we can venture an opinion, 
the urine which is secreted is scanty, of low specific gravity, contain- 
ing a small quantity of albumen, and very defective in urea and the 
other excretory matters." 

5. The fifth form of Bright's kidney is that commonly known as 
the hard, granular, or contracted kidney. The kidneys are smaller 
than in health, generally about half the size; the surface of the organ 
is uneven and puckered, what in fact might be termed hobnailed, 
the tunic adherent, and the surface of the organ apt to be lacerated 
in the attempt to detach it. The essence of the disease being a 
degeneration, or atrophy of the secreting structure, which is in some 
parts so narrowed that the bases of the tubular cones almost reach 
the surface of the organ: there is no deposit in the tubes, but the 
degeneration consists of a large increase of fibrous tissue, which, by 



CHANGES IN" THE BLOOD. 389 

its subsequent contraction, strangulates and atrophies the secreting 
cells, much as in the case of advanced cirrhosis of the liver. The 
urine secreted by the kidneys in this form of disease, may or may 
not be albuminous; often it is not so; or when albumen is present, 
it is in very small quantities ; it is, however, of very light specific 
gravity, sometimes as low as 100*5, and very scanty. The essential 
characteristic of this form of disease is a suppression of the excretion 
by the kidneys, of the natural solid ingredients of the urine. 

6. The sixth form of this disease, is that which was termed by the 
late Mr. T. W. King the " coarse kidney." The organ in this form 
is large, dark, not unlike that of the first form, being, in fact, in a 
state of hyperemia, the result, generally, of a certain amount of 
mechanical obstruction, arising from impediment to the circulation 
through the right heart. The pathology of this affection appears to 
consist in a passive hyperemia, upon which has supervened some 
subacute inflammatory action, induced perhaps by a fresh attack of 
the original disease (chronic bronchitis for instance), or excited by 
the exposure to cold, or the impression upon the skin or other mucous 
surface which produced that fresh attack. The urine in this form of 
the disease is always scanty, generally of high specific gravity, loaded 
with urates, and containing but a moderate quantity of albumen ; 
when rendered turbid by lithates, it generally becomes clear upon 
the first application of heat, but as the heat is continued, it becomes 
again turbid from the deposition of albumen. 

We cannot quit the subject of Bright's kidney without some 
allusion to the fatty degeneration of the organ, to which for some 
time much importance was attached, it being supposed to constitute 
the primary and efficient cause of large numbers of cases. Further 
observation has, however, tended to show that fatty change is rather 
an effect, and a sign of previous disease, than any way concerned in 
the etiology of the disease itself; thus, for instance, we have seen 
that one of the sequels of inflammatory action may be fatty change, 
and accordingly the inflammatory exudation into the tubes, in the 
large white kidney, may eventually become fatty ; and in a similar 
manner, the small, granular kidney may be very fatty, though both 
these conditions may occur without any fatty deposit whatever. 

Such, then, are the general characters of the morbid changes, which 
constitute the fundamental lesion, in the large class of diseases which, 
for convenience' sake, we term Bright's disease: and such being the 
differences in the immediate effects of that disease (hj which we 
mean the different modes in which the urine is altered from the 
normal state), which effects become in their turn the potential causes 
of other diseases, we naturally expect that those other diseases must 
be of very different characters ; and further, since the alteration in 
the quality of the urine is of such a nature as materially to influence 
that of the blood itself, we should also be led to expect that these 
secondary or remoter diseases might attack the system wherever the 
blood is distributed, or, in other words, that any part of the body may 
become affected. 

Of the changes in the blood itself, the first, and most obvious, is 



390 beight's disease. 

the diminution in the solid ingredients — albumen and red globules, 
and after a time in the fibrine also. In all the first three forms of 
disease, in which the urine contains a large quantity of albumen, there 
is soon a notable deficiency of that substance in the blood, which has 
the effect of reducing its specific gravity much below the natural 
standard, sometimes as low as 1015 or 1010. When, as is often the 
case, the red corpuscles are likewise present in the urine, they also 
speedily become defective in the blood ; but in many instances, of 
the' second form more particularly, in which the urine is highly 
albuminous, there are no red corpuscles, and in these there is no 
notable deficiency of red corpuscles until the disease has existed for 
a considerable time, after which the corpuscles as well as the alubmen 
become defective. The same thing nearly is the case with the fibrine, 
which is not defective in quantity, but on the contrary is sometimes 
in excess at the commencement of the disease, and continues to be so 
even after a notable decrease in the. albumen and red corpuscles; it 
is owing no doubt to this, that the blood when drawn is often buffed, 
and sometimes cupped ; later, however, in the progress of the disease, 
the fibrine also becomes defective, falling as low as 2 or 1 J per mille. 
The other effect upon the blood, which may be regarded as a potential 
cause of disease, is the retention in the blood of the excretory matters, 
urea, uric acid, &c. Owing to their non-elimination by the kidneys, 
these substances, more particularly the urea, from its greater abund- 
ance, may be readily detected in the blood ; and so retained they act 
as poisons, or irritants upon the nervous system, the serous mem- 
branes, the coats of the arteries, and other tissues. The principal 
changes thus produced upon the blood may be summed up as a 
deficiency of albumen, red corpuscles, and, ultimately, of fibrine also, 
or, which amounts to nearly the same thing, a proportionate excess 
of water, and the presence of a large quantity of excretory matter. 

As a result of the change in the blood, we may first notice deopsy. 
This indeed was the symptom, or, as it was then considered, primary 
disease, which drew attention to the abnormal changes in the urine 
of which we have been speaking, and to their subsequent connection 
with disease of the kidney. This dropsy shows itself in the greatest 
degree in those cases in which the urine is most albuminous, and the 
blood most abundant in water ; and it is, no doubt, mainly owing to 
this cause ; but, as serous effusion may be excited by irritation either 
of the general areolar tissue of the body, or of the closed sacs, we 
can readily believe that the presence of an irritating matter will 
produce the same effect. We have, therefore, two causes at work, 
which may be considered to co-operate in producing the effusion. 
This effusion is in greatest abundance in those cases in which there 
is the greatest drain from the blood, that is to say, in the first three 
forms of the disease, and in such cases it shows itself mostly in the 
form of general anasarca, though this may be accompanied by effusion 
into the serous cavities of the head, chest, or abdomen. It is, per- 
haps, in the more advanced stages of the second form of the disease, 
that, namely, of the large white kidney, in which we have a coincidence 
of the two causes, a great drain of blood-matter — and a very defective 



MUCOUS INFLAMMATION AND HEART DISEASE. 891 

elimination of nrine-matter, — that we meet with the greatest amount 
of effusion, both general and into the serous cavities ; the latter form 
of effusion being often of a highly-inflammatory character, and con- 
taining a considerable quantity of fibrinous or molecular lymph. In 
the fourth and fifth forms of the disease, especially the latter, in which 
there is little or no albumen passing off by the urine, we may often 
have no dropsy, or scarcely any, though there may be sudden effusion 
of an inflammatory character, from the effect of the retained excretory 
matter in the blood. This, however, belongs more properly to the 
serous inflammations to be presently noticed. 

Before quitting the subject of dropsy, we may notice its tendency 
to affect the sub-mucous areolar tissue throughout the body; this 
effusion may, no doubt, like those last mentioned, be sometimes of 
an inflammatory character, and where we have two causes in opera- 
tion, the one leading to dropsical effusion and the other exciting a 
degree of inflammation which may also induce similar exudation, it 
is difficult to draw the line : but it may be of practical utility to bear 
in mind, both — that those effusions which occur in such abundance 
in this disease, and which we are prone to regard as mere exudations, 
may partake in some measure of the inflammatory character, — and 
also, that others which from their situation, as well as other pheno- 
mena attending them, may suggest to our minds the notion of inflam- 
matory affections, may, in reality, have much of the character of passive 
effusion. We particularly allude to the bronchial membrane, a sub- 
mucous effusion affecting which may, and often does produce, in con- 
nexion with diseased kidney, sibilant and other ronchi, which we are 
very prone to associate with more active bronchitis. Another form 
of sub- mucous effusion, which is very common in all the varieties of 
this disease, is underneath the conjunctiva, producing the appearance 
of a watery eye ; but when more closely regarded, it will be found 
that the appearance is not produced, as it seems to be, by a tear 
resting on the eyelid, but by an accumulation of fluid beneath the 
epithelium, which, gravitating towards the lower lid, causes the con- 
junctiva to overlap it, producing a kind of watery chemosis. This 
effusion is one of the most characteristic signs of renal disease, and 
has several times been observed in cases in which no other dropsical 
effusion whatever was to be detected, especially in those cases of the 
fourth and fifth forms of disease, in which there is a tendencv to 
cerebral complication. Whether this may have anything to do with 
disturbance of the cerebral circulation, or impending effusion, may 
be worth investigating. 

Another characteristic of the dropsy from the diseased kidney is, 
that when it assumes the form of general anasarca, it always affects 
the genitals, being particularly noticeable in the penis and scrotum, 
it also differs from the dropsy produced by disease in the liver, in 
its not being confined, even at the commencement, to the lower 
extremities, but affecting also the upper, as well as the face, where it 
particularly shows itself beneath the eyes. Purely renal anasarca 
differs from the purely cardiac in the absence of the lividity, and 



392 beight's disease. 

other signs of congestion, which almost always accompany the latter 
but in practice these causes of dropsy often concur. 

We have just spoken of the effusion under the mucous membranes 
as a form of dropsy; but we must add, that inflammations of these 
membranes are among the consequences of Bright's kidney; these 
we meet with in every form of the disease, though perhaps more 
particularly in the more advanced stages. Mucous inflammation 
shows itself in the form of bronchitis, which is a very common effect 
of Bright's kidney. Dr. "Wilks, in the paper above quoted, states it 
as his belief, founded upon most extensive observation, that it is the 
most common next to albuminous urine. 

Another shape in which mucous inflammation or irritation pre- 
sents itself in Bright's kidney is in that of the gastro-intestinal 
mucous membrane, in the form of vomiting and diarrhoea, generally 
of a dysenteric character. The connection between inflammation of 
the kidneys and vomiting we have already pointed out; but inde- 
pendently of this, there appears to be an effort at a vicarious elimi- 
nation of the retained secretion by this membrane. 

Inflammation of serous membranes has been alreadv alluded to, 
and it was one of the effects of Bright's kidneys which first attracted 
attention. It is very probable that the two conditions of the blood, 
namely, the defect in the quantity of red corpuscles and the presence 
of excretory matter, concur in inducing this kind of inflammation, 
the former by causing a susceptibility of such inflammations, as we 
have seen (p. 60), and the latter by acting as a direct or efficient 
cause. That the presence of the urea in the blood is an efficient 
cause is evident from the fact, that urea is capable of exciting such 
inflammation: and that it is present in the effusions which take 
place into the serous cavities in this disease is well ascertained, it 
having been in different instances detected in every one of them. 
These inflammations are often of the most sudden and violent 
character, — an attack of pleuritis or pericarditis sometimes proving 
fatal in the course of twenty-four hours. The pleura and pericar- 
dium are the serous membranes most liable to become affected in 
this manner; and next in order are the arachnoid and peritoneum, 
the former perhaps the most frequently. It is true that affections of 
the encephalon frequently occur, but they depend probably upon 
another condition of the brain to be presently noticed. 

Another common consequence of the Bright's kidney is disease of 
the heart and large vessels. The excretory matters present in the blood 
appear to act as stimulants, inducing an inflammatory action in the 
endocardium and lining of the arteries, the consequence of which is 
thickening and puckering of the valves, and contraction of the orifices; 
the valves and endocardium on the left side being mainly affected. 
As an effect of this endocardial affection, either direct or through the 
narrowing of the orifices, that of the aorta especially, we find the left 
ventricle to become dilated, and, most commonly, at the same time 
hypertrophic, upon the principles already explained (p. 380). The 
chronic changes in the valves may also give rise, as in other forms of 
endocarditis, to obstruction or regurgitation, with their effects upon 



CEREBKAL AFFECTIONS. 393 

the circulation. The action of the blood upon the lining of the 
arteries is of an analogous character, the membrane becoming 
opaque, and the other coats of the artery thickened and contracted, 
the effect of which is to cause irregularities in the circulation, espe- 
cially in the cerebral arteries, which are particularly liable to these 
changes; thus either apoplexy may ensue from extravasation, or 
from sudden arrest of the circulation; or the circulation being only 
partially impeded, we have the more gradual effect of softening from 
imperfect nutrition. 

The substance of the lungs is not so frequently the subject of 
inflammation in Bright's disease as are the pleurae and bronchial 
tubes. Still, in a considerable number of cases we find hepatisatidn 
and induration of the lungs, not to mention that the state which we 
commonly describe as oedema is often the effect of inflammatory 
action, the greater quantity of fluid in the blood in excess over that 
of plastic matter, inducing this form of effusion. The coincidence of 
pneumonia with albuminuria has been sufficiently common to sug- 
gest that it may be the cause of the latter; but the more advanced 
condition of the renal disease in all fatal cases of this kind, seems to 
answer the question in the negative. 

Besides the affections of the brain arising from the changes in the 
arteries, we have cerebral symptoms produced by the direct poisonous 
action of the retained secretion upon the nervous matter; this is, in 
fact, the most sudden as well as one of the most dangerous conditions 
of the toxaemic condition, which plays so conspicuous a part in the 
phenomena of this disease. These affections are, either sudden con- 
vulsion, passing not unfrequently into coma, with a remarkable 
stridulous breathing; or, which is a very characteristic form of cere- 
bral affection, we have a state of "quiet stupor," to use the words of 
Dr. Addison, which may continue for a considerable time, out of 
which the patient may recover if the elimination of the poison can 
be established; but if this do not take place, the stupor gradually 
assumes the form of most profound coma. These affections of the 
nervous system belong entirely, if we may so speak, to the aneccritic 
element of the disease; as shown by their presenting themselves in 
other affections in which the uraemia is induced by retained secretion, 
as in the retention of urine, and it may be in cholera, but in which there 
is no elimination of urine-matter by the urine. This state also appears 
to be a form of narcotism, resembling in many respects those induced 
by opium and by alcohol. The pupil is sometimes obedient to light, 
never dilated, and in many instances contracted. 

Another nervine affection often met with in Bright's disease, is the 
occurrence of cramp in the limbs, especially in the lower extremi- 
ties; the etiology of this affection is somewhat obscure, though its 
frequent occurrence is undoubted. It seems to take place most fre- 
quently in the earlier stages, so much so, that in many cases of some 
standing, the period of the commencement of the disease may be 
inferred from this symptom; it may possibly depend upon the great 
diminution in the quantity of the urine and consequent uraemia, 
which often marks the commencement or more acute stage of the 



394 b right's disease. 

disease. It is somewhat remarkable that this is a prominent symp- 
tom in cholera, in which likewise uraemia exists in a remarkable 
degree. 

Having detailed the principal elements, so to speak, which make 
up this remarkable disease, we are in a position to treat of it as a 
whole. 

In the first three forms of diseased kidney which we have described 
above, we have the first, which is essentially acnte, and the second 
and third, which may be either a chronic form of the first, or have 
been from the commencement subacute or chronic affections. 

In cases of the first we have generally a history of exposure to the 
cold, or an attack of scarlatina; and about a fortnight afterwards, 
there are observed chills, heats, thirst, a dry skin, and almost simul- 
taneously with these, puffin ess of the face, or oedema of the feet and 
ankles. About the same time the urine is observed to be very 
scanty, and often dark, though there may be frequent calls to void it. 
Upon examination the secretion is found to be such as has been 
described as belonging to the first form. The oedema in many cases 
rapidly extends, so that the whole of the surface of the body becomes 
highly anasarcous: and this anasarca commonly extends to other 
parts, so that we may have oedema of the lungs or epiglottis. There 
is also a great tendency to effusion into the serous cavities, especially 
the peritoneal, so that it is rare to find a case which has gone to this 
extent without some amount of ascites. It is often when the disease 
has just obtained this point, that we first see our patients, when we 
find them largely ©edematous, the cheeks and eyelids much swollen, 
the conjunctiva overlapping the lower lid, the skin hot and dry, and 
the pulse sharp; if the disease do not subside or yield to treatment, 
the urine may become more abundant, but retain the same proportion 
of albumen ; the countenance will become more bloated and doughy, 
the prolabia paler, the patient more unwieldy and distressed, and 
considerable dyspnoea is now experienced; the pulse at this period 
is generally moderately full and sharp, though not very difficult of 
compression. If the disease still continue to advance, the oedema 
may extend from the areolar tissue at the root of the lungs to the 
lungs themselves, and become such as to cause death from apnoea; 
or the rima glottidis may become cedematous to such a degree as 
entirely to close the chink ; or sudden effusion may take place in the 
chest or pericardium, by which life may be endangered; and the 
same thing may occur, though perhaps but rarely, on the surface or 
into the cavities of the brain ; or there may be effusion into the air- 
cells, or the bronchial tubes become so swollen as to produce the ill 
effects of oedema of the substance of the lunsrs themselves. Death 
from direct uraemic poisoning in this form is rare, that is to say, from 
its direct influences upon the nervous substance; but there may be 
sufficient uraemia to produce serous inflammations which may be 
fatal. Still it is not saying too much to assert that when death takes 
place in the acute form of Bright's disease, it is more commonly from 
the effects of the effusion than from uraemic poisoning. 

It more commonly happens that the disease assumes one of the 



HISTORY AND SYMPTOMS. 395 

sub-acute or chrome forms 2 and 3. These occur either at more 
advanced stages of the first form, or they may commence insidiously, 
and preserve the chronic character throughout. When this is the 
case, there may be scarce any symptoms to mark the commencement 
of the mischief. Sometimes there . will be increased frequency of 
micturition, and the urine may be absolutely increased in quantity; 
often too it is of the smoky appearance, though there may be no 
deviation from the natural colour. Sometimes, too, there will be pain 
in the loins and across the epigastrium, or there may be cramps in 
the lower extremities, especially at night. The next symptom will 
generally be oedema, commencing at the legs or ankles, but soon 
affecting the face, and often producing the appearance of the conjunc- 
tiva already noticed, the countenance becoming, all this time, more 
and more bloated and anaemic. The oedema may now extend rapidly, 
and the swollen, bloated aspect of the patient, which when once seen 
cannot be readily mistaken, is highly characteristic of this form of the 
disease. It cannot, perhaps, be better described than in the words of 
a sailor in Guy's Hospital, the subject of it, who said he was com- 
pletely "water-logged;" and either oedema of the lungs or epiglottis, 
or effusion into any of the serous cavities, may suddenly take place ; 
we may also at any time have active inflammation of the serous or 
bronchial membranes, or irritability of the stomach, or dysenteric 
diarrhoea may supervene. It is perhaps in this form of Bright's dis- 
eases that we most frequently have to encounter the active serous 
inflammation of uraemia, which is apt to prove fatal, more particularly 
if it affect the pericardium ; we may, too, have the sudden invasion of 
cerebral symptoms, from the direct effect of uraemic poisoning upon the 
brain ; or we may have disease of the heart and arteries, from inflam- 
mation of the lining membrane, producing thickening and rigidity 
of the arteries generally, (which may often be felt most distinctly at 
the wrist,) and in the brain softening from defective nutrition, and 
extravasation ; the obstruction of the circulation also induces hyper- 
trophy or dilatation, or both, of the left ventricle of the heart. 

In the most chronic form of the disease, which is generally that in 
which we find the fourth and fifth forms of the Bright's kidney, the 
symptoms are even more insidious ; there may be no dropsy of any 
kind, though in most instances there is oedema of the feet and ankles, 
and slight puffiness under the eyes ; in this form of the disease we 
may have the oedema beneath the conjunctiva producing the watery 
chemosis already described, even when there is no other dropsical 
swelling to be detected. This state of things may go on for a length 
of time, the patient not making much complaint or suspecting the 
presence of serious illness ; until either from some accidental cause, 
inflammation within the chest, generally of the bronchial membranes, 
leads him to seek advice, when the true nature of his illness is 
detected; or what is even more common, the chronic change of the 
endocardium and arteries above described having been insidiously 
going on, he becomes the subject of palpitation and dyspnoea, from 
disease of the aorta or large arteries, when a careful inquiry leads to 
examination of the urine, which may, however, be found to contain 



396 beight's disease. 

little or no albumen, but it will almost always be of light specific 
gravity, or if not so, absolutely, it will be so, in proportion to the 
small quantity excreted, thus evidencing the scanty elimination of its 
normal solid ingredients. In other cases, again, the first evidence of 
disease may be the invasion of cerebral symptoms, either suddenly 
in the form of apoplexy, from extravasation, or by the arrest of circu- 
lation, from universal thickening and rigidity of the cerebral arteries, 
or we may have the sudden stupor or other cerebral disturbances 
pointed out by Dr. Addison as the direct effect of the retained secre- 
tion upon the nervous matter. (Gruy's Hospital Reports, vol. iv. p. 1.) 

In this class of cases the chief cause of the symptoms is the retained 
secretion acting as an irritant or narcotic poison upon the organs of 
circulation, upon the serous and mucous membranes, or upon the 
nervous centres; it seems, too, at times, to act upon the extreme cir- 
culation, producing a degree of collapse with lividity, not very 
dissimilar in kind from cholera. This form of diseased kidney is 
often associated with the rheumatic or gouty diathesis, and may pro- 
bably be the effect of a chronic gouty inflammation of the kidney. 

The congestive form of Bright's kidney, if indeed it deserve the 
name, is essentially a secondary one, and the symptoms are mainly 
referable to the disease which produced it, that is to say, to obstructed 
pulmonic circulation, and consequent venous engorgment. Its exis- 
tence will, however, aggravate the effects of the primary disease ; 
and when it supervenes upon an organ already diseased, as by either 
of the preceding forms, the consequences of retained secretion may 
be expected to declare themselves more rapidly. 

The diagnosis of Bright's kidney was for many years considered 
to be exceedingly simple ; the presence of albumen in the urine, if 
there were no haemorrhage to account for it, being considered a suffi- 
cient sign of its existence, and its absence a certain proof of its non- 
existence : the discovery, however, by more extended clinical expe- 
rience, that albumen may not be found in the urine, however 
carefully tested, though the kidneys may be almost destroyed, as 
regards the performance of their most important offices, has shown 
that we must look to other conditions either of the urine or of the 
system generally, to guide us. In the first three forms of disease we 
have less difficulty, as the urine is in them always albuminous ; and 
as in those cases the inflammation is mainly in the tubes, constituting 
a state of things analogous to bronchitis of the lung, we have gene- 
rally a desquamation of renal cells, which may be recognised under 
the microscope ; and their presence has been regarded by Dr. Gr. 
Johnson as diagnostic of these forms of the disease : but this does 
not always hold true, since in many undoubted cases these cells are 
not to be found. The abundance of albumen, and the extent of 
dropsical effusion on the other hand, constitute more appreciable as 
well as more constant signs of this form of the disease. 

In the hard granular kidney there is more difficulty, as the urine 
may be free from albumen throughout ; though even here, if it be 
repeatedly tested, a slight deposit of it may in most cases be at some 
time obtained ; added to which, the secretion will be either very 



DIAGNOSIS AND CAUSES. 397 

scanty or of exceedingly light specific gravity, and with but little 
urinous odour when boiled or treated with nitric acid, showing the 
exceedingly scanty elimination of urea. 

The causes of Bright's disease are in the first instance either expo- 
sure to cold, especially when the skin is in a state of perspiration, 
and scarlatina ; the acute form of the disease may also be induced 
by the injudicious use of substances having a powerful diuretic 
action. The second or more chronic form of the disease, no doubt, 
is often a consequence of the first, but it appears often to have crept 
on gradually without any acute stage, and to have been caused, as 
far as we can judge, by the more gradual operation of causes similar 
to those which produce the first, more frequently repeated, though 
applied in less intensity. Amongst the stimulating causes by which 
this affection of the kidney may be induced, we may reckon the use 
of ardent spirits, more particularly gin ; but it is probable that, how- 
ever prolific of disease in other ways, its direct agency, as a cause of 
renal disease has been much over-estimated ; but there can be no 
doubt that intemperance, especially in the form of dram drinking, 
so common amongst the lower orders in large towns, not only, by 
the cachectic state which it induces, renders the individual more sus- 
ceptible at all times of the direct causes of the disease, but also the 
relaxed and enfeebled condition both of the nervous and vascular 
systems which succeeds the excitement produced by alcohol, 
greatly aggravates this susceptibility, and renders the subject of it 
at such times peculiarly liable to become affected by the slightest 
exposure. It is probable for these reasons that renal disease, more 
especially in this form, is so extensively prevalent in London and 
the other large towns in this kingdom. 

The causes which induce hard contracted kidney are still more 
obscure, owing in great measure to this form of renal disease differ- 
ing from the others not only in the nature of the degeneration, but 
also in the absence of all symptoms by which the progress of the 
disease is marked, the first intimation of its existence being derived 
from that impaired function of the organ which is the consequence 
of the morbid change, or from those still more remote consequences 
— the effect of that impaired function upon other parts of the system. 
It may be, no doubt, in many instances, associated with a gouty dia- 
thesis, but that this diathesis is its alone cause there is by no means 
satisfactory evidence. It is observed most frequently either in 
advanced life, or in those who have worked hard, or lived hard. 

The prognosis of this disease is, no doubt, in the main unfavoura- 
ble ; but in each particular case much must depend upon its probable 
character and previous duration. The first form of the disease is 
rarely fatal as such, the great danger being that it will pass on to the 
second stage or form. In early cases of scarlatinal dropsy we have 
every reason to believe that we still have the former condition to deal 
with, and, therefore, the prognosis is upon the whole favourable. In 
the non-scarlatinal cases, the difficulty is to ascertain whether we 
really have a very early case to deal with, or one of the more chronic 
forms of the white or mottled kidney, in which the disease has been 



398 beight's disease. 

• 
for a long time insidiously making way, although the patient may 
have only just become aware of his illness. An appearance of the 
lips and countenance denoting a tolerable abundance of red blood, 
a specific gravity of the urine nearly approaching to the natural 
standard, and a well-marked history of the recent invasion of the 
disease, confirmed by evidence of previous good health, are favoura- 
ble symptoms ; whilst a doubtful history of the commencement of the 
illness, and of the previous health of the patient, a very low specific 
gravity of the urine, and above all evidence of the secondary effects 
of urgemia upon other organs, are unfavourable signs. In proportion 
as we are sure that the disease has passed from the stage of engorge- 
ment to that of disorganisation, in the same proportion may we be 
certain that recovery is not to be expected, and in proportion as we 
have signs of advancing secondary disease from ursemic poisoning, 
in the same proportion may we apprehend a speedy termination. In 
the cases of the hard contracted kidney, the ultimate prognosis is 
equally unfavourable, and the patient is at all times liable to sudden, 
and possibly fatal attacks of disease, either of the heart or encephalon, 
though it is to the latter that he is more especially liable. It is, 
however, true, nevertheless, that patients may go on under careful 
management, with this form of renal disease extending from late in 
the middle period of life to an advanced age. 

The treatment of this disease has been reckoned among the oppro- 
bria medieinae; and undoubtedly a large number of cases are beyond 
the reach of any means we posses, as regards the removal of the 
lesion which is the primary cause of the most serious symptoms; 
but this arises from our having to do not so much with the diseased 
action producing structural change as with the consequences of de- 
stroyed function resulting from a structural change already effected 
by that diseased action. Under which circumstances it is no more a 
reproach to medicine that it cannot restore to its healthy and efficient 
condition a kidney that, as far as that part of its structure upon which 
its action as such is concerned, has ceased to be a kidney; than it is 
to surgery that it cannot restore a limb already destroyed by disease 
or accident. In those cases, however, in which we have to combat 
the disease itself, and not the effects of those changes which the 
disease has effected, art may yet do much. It is only, however, in 
the first form of B right's disease that we are so favourably circum- 
stanced. 

In the case of the active congestion of the kidney there are two 
distinct indications to be fulfilled. In the first place we must en- 
deavour to subdue the inflammatory action by general treatment, and 
promote its subsidence in the affected organs by measures directed 
specially to them ; and secondly, we must endeavour to obviate the 
effects upon different parts of the system of the impaired and per- 
verted function of a vital organ. In some acute cases, in the early 
stage, when there is reason to believe that the health has been pre- 
viously good, as in the case of scarlatinal dropsy in a sound subject, 
blood has been often taken from the arm with benefit; but that this 
may be safe we must not only have the above conditions, but we 



CAUSES AND TREATMENT. 399 

must have a sharp and firm pulse, a hot skin, and a complexion evi- 
dencing that the blood has not yet been materially impoverished by 
the drain through the kidneys. Such cases are indeed mostly con- 
fined to those occurring after scarlatina, owing to the comparative 
infrequency of our seeing other cases at a sufficiently early stage. If, 
however, there be a sharp and tolerably firm pulse with hot skin, 
and there be any doubt as to the tolerance of general depletion, six 
or eight ounces of blood may be taken from the loins by cupping. 
As a general rule, however, where there is pallor, blood should not 
be abstracted. The next and most generally useful means of ful- 
filling this indication is antimony, which at once lowers the action of 
the heart and large arteries, relieves congestion in the extreme 
circulation, and promotes the cutaneous secretion. It may be given 
either in the form of pill, with henbane (F. 74),* which will perhaps 
be best borne when the stomach is irritable, otherwise it is best to 
use it in solution, beginning with a sixth or a quarter of a grain. In 
the commencement, a saline mixture, such as a solution of citrate of 
potass or acetate of ammonia, may be used as a vehicle ; but when 
the disease has lasted long enough to impoverish the blood, salines, 
which are spansemics, are to be avoided, though the acetate of am- 
monia is less liable to this objection than others. Gentle warmth 
should be at the same time employed to encourage perspiration, and 
to this end a linseed poultice applied across the loins will often be 
found serviceable. 

As in these cases the urine will generally be scanty, indeed in the 
acute stage it always is so, and the system surcharged with fluid, 
showing itself in the form of great and general anasarca, the question 
arises, are we to employ diuretics? As a general rule, direct diu- 
retics should not be employed during the early stages of the inflam- 
matory form of Bright's disease any more than we should administer 
active purgatives in inflammation of the bowels. It will, however, 
often happen that under the guarded use of depletion which has been 
enjoined, and of the antimonial medicines, the urine from having 
been very scanty and loaded with blood-matter will become much 
more abundant, and though still containing both red corpuscles and 
albumen, the proportion will be much less, and, by this healthy diu- 
resis, much of the redundant fluid may be carried out of the system 
without further injury to the kidneys. But even when this is going 
on we must endeavour to save those organs as much as possible by 
encouraging the escape of fluid through other outlets. With this 
object we must continue the diaphoretic treatment, and at the same 
time have recourse to moderate hydrogogues. For this purpose the 
compound jalap powder of the Pharmacopoeia is a most useful com- 
bination. Elaterium, though a most valuable hydrogogue, is to be 
avoided in this period of the disease, from its tendency to irritate the 
mucous lining of the intestinal canal. Jalap and calomel may also 

* (74) R. Antim. Pot. tart. gr. J. 
Extr. Hyoscy. gr. iv. 
Ft. Pil. ; to be repeated every 4th or Gth Lour. 



400 bright's disease. 

be occasionally used with advantage in the early stages, particularly 
in scarlatinal dropsy in young subjects. When the antimony has 
been continued for a few days, and no irritating or inconveniently 
depressing effects produced, it may be further increased, and its use 
continued until the action of the skin has been established and the 
pulse has become soft. 

In some cases, the scarlatinal ones more especially, we find the 
anasarca disappear and the urine lose its albumen under this plan of 
treatment, after which, by a more liberal diet, careful avoidance of 
cold, and gradual return to exercise in the open air — the importance 
of which in maintaining the healthy action of the skin in the conva- 
lescence from the acute form of this disease, as well as in some periods 
of the chronic forms, is not sufficiently appreciated — the patient will 
gradually regain his colour and strength, and recovery may be even- 
tually completed, though the greatest care will for a long time be 
necessary, lest by any imprudent exposure or repressed action of the 
skin the kidneys should be overstimulated and resume their diseased 
action. 

One of the great difficulties in the management of this form of 
the disease has been already alluded to, namely, irritability of the 
stomach, which is amongst the most prominent symptoms of inflam- 
matory affection of the kidneys, and is peculiarly embarrassing in 
such cases, as it prevents the use of the antimony, which is the remedy 
upon which most reliance is to be placed. Under such circumstances 
the stomach should be as little disturbed as possible, the very least 
quantity of liquid, to allay thirst, should be allowed, and if there be 
not extreme debility, recourse should be had to cupping at the loins ; 
and should this be deemed inadmissible, the dry cupping may be 
employed; sinapisms should be at the same time applied to the pit 
of the stomach, and the functions of the skin may be promoted by 
vapour-baths. Should the bowels not be acting freely, an enema 
containing jalap (F. 75)* will also be a rational means of unloading 
the system of some of its superfluous water, and determining from 
the kidneys. By these means we may subdue the more active irrita- 
tion of the kidneys and relieve the consequent sickness, and thus 
prepare the way for the antimonial treatment. 

It sometimes happens, however, in the progress of these acute cases 
that we have the sudden supervention of head symptoms. When 
this occurs with very scanty urine, especially if that urine contain 
blood, leeches or cupping may be used over the loins; in adults the 
latter should be preferred, and unless there be dysenteric irritation 
the jalap and senna enema may be used. If the cerebral oppression 
continue, dry cupping at the neck may be employed, and if that fail 
a blister may be applied in the same situation, but in all the earlier 
cases of this disease it is better to avoid the use of such a remedy 
where it can safely be done, lest the lytta should irritate the kidneys 
by absorption into the circulation. 

(75) R. Pulv. Jalapse, 3 i. 

Infus. Sennse co. fervent. i§ viij. Misce. 
Ft. Enema. 



TREATMENT. 401 

Tlie question has frequently been raised, 'as to how far this inflam- 
mation may, like several others, be subdued by mercury ; experience 
answers that it seems but little amenable to such treatment; and, 
further, that there is conditions connected even with the earlier 
period that render mercury a dangerous remedy; first, because there 
is present, sooner or later, a deficiency of red corpuscles, which is 
always aggravated by mercury; secondly, because, though there may 
be no great degree of pallor, or manifest signs of that state of the 
system which is usually admitted to contra-indicate mercury, the 
mouth and fauces often become suddenly and violently affected by it, 
when this state of the kidneys exist, even in so slight a degree that 
the intolerance of mercury is the first symptom which draws atten- 
tion to the state of the urine ; and, lastly, because, in cases where the 
disease has probably been in an early stage, and the remedy has been 
very cautiously administered it has produced disorganising effects, 
which can only be accounted for by the supposition that the presence 
in the blood of retained secretion greatly diminishes, or almost des- 
troys that vitality of the tissues by which the tendency to such 
effects is counteracted. This sometimes shows itself in rapid gan- 
grene of the anasarcous extremities.* 

In the less acute, and more protracted form of this disease, namely, 
the large white and mottled kidney, we must still keep in view the 
principle of relieving the circulation of the excess of fluid and the 
excretory matter which it contains, with the least possible excitement 
of the kidneys. For this purpose, when there is no great debility, 
we may still have recourse to the antimony, especially if the skin be 
hot and dry. The hydrogogue cathartics may also be employed, 
either in the form of half a grain of elaterium with eight or ten of 
bitartrate of potass, or the elaterium may be administered, in very 
minute doses, say one-twelfth of a grain every three or four hours; 
but in either case we must guard carefully against its irritating 
effects upon the lining of the stomach and large intestines. In the 
more advanced stages we may, however, have recourse to gentle 
diuretics, as we use expectorants in chronic bronchitis. Of diuretics 
the safest will be the least stimulating, and therefore when there is 
no great feebleness in the action of the heart, digitalis in the form of 
infusion, in doses of from one to two drachms, may be employed, and 
with this may be combined the nitric aether. Salines are hardly 
admissible, not so much on account of their tendency to stimulate the 
kidneys as from their increasing the spaneemia which already exists ; 
though this objection does not apply so much to the salts of ammonia, 
of which we may sometimes employ the acetate, or a draught con- 
taing the citric acid saturated with ammonia (F. 76).f 

* See Guy's Hospital Reports, Second Series, vol. i. p. 205. 

f (76) R. Acidi Citrici, £)j. 

Amnion. Sesquicarb. gr. xv. 
Sp. Mth. nit. gss. 
Syrupi Aurant. g ss. 
Aq. Purse vel Mist. Camphors?, g xi. 
Ft. liaust. ; to be taken three times a-day. 

26 



402 b right's disease. 

In this form of the disease, serous inflammations are very apt to 
arise; and there is some difficulty in subduing them owing to the 
intolerance of mercury. The best means will be cupping in small 
quantities, the application of blisters, the use of the antimony with 
digitalis, and purgatives, either in the shape of elaterium or com- 
pound jalap powder. In cases where there is too much irritability of 
stomach for the former, and the latter has not acted sufficiently free, 
the draught of tartrate of potass, manna, and senna, will sometimes 
bring away a considerable quantity of fluid with but very little irrita- 
tion. The use of hydrogogues is indicated in this form of the disease 
by the tendency which exists to great serous effusion upon the occur- 
rence of slight inflammatory action, or even without, and this is 
peculiarly the case in the lungs and the bronchial membrane, and 
the areolar tissue about the glottis. 

"When this last occurrence takes place, which is indicated by dysp- 
noea, with a whistling respiration, in addition to the above remedies 
hot fomentation, or rather flannels wrung out of nearly boiling water, 
must be applied to the throat, and a blister to the back of the neck. 
Should these measures fail tracheotomy may be had recourse to. 

The oppression of the system by the universal dropsy, which gravi- 
tates more particularly into the scrotum and lower extremities, sug- 
gests the expediency of puncturing the surface to give it exit. This 
may occasionally be done with advantage, but the punctures or in- 
cisions should never be in the legs, owing to the great tendency to 
gangrene ; sometimes the scrotum may be punctured, but as a general 
rule the thighs are to be preferred. The safest plan is to make a few 
small incisions with the point of a lancet, which will generally dis- 
charge sufficiently freely, though otherwise the puncturing needles 
may be employed, as recommended by Mr. Hilton; but the greatest- 
care must be taken to keep up the warmth of the part by the use of 
warm fomentations of flannel. 

When, after we have succeeded in removing the dropsical effu- 
sions, and apparently arrested the disease, or, at all events, subdued 
the more urgent symptoms, the anasmic conditions remain, kept up 
by the continued discharge of more or less blood-matter by the kid- 
neys, tonics appear to be indicated ; and for this purpose preparations 
of iron have been recommended. Their use, however, requires the 
greatest caution, from the tendency to head affections. Perhaps the 
safest form in this disease is the tinct. ferri sesquichlor., which may 
be administered in doses not exceeding ten minims. As a general 
rule, however, iron is not a safe remedy ; zinc will be found much 
more so, of which the sulphate may be employed in doses of from 
one to five grains. The good effect of zinc as a tonic will often be 
apparent, and by its astringent properties it may be useful in restrain- 
ing the discharge of albumen ; for this latter purpose gallic acid has 
been employed, and it is said with benefit. 

It is apparent from what has already been said, that in these forms 
of the disease we have to deal more with its secondary effects than 
with the disease itself; yet if we can succeed in overcoming this, we 



aa^^^m^m 



TREATMENT. 403 

may direct our attention more to the primary affection, not so much 
with the hope of its entire removal as with a view to checking the 
morbid action going on, and so preserving, for the longest possible 
time, the portion of the organs not irretrievably injured. When we 
have the symptoms of an acute affection supervening upon a chronic, 
we must follow the plan of treatment already recommended for the 
acute cases; but when we have succeeded in subduing the urgent 
symptoms, and have, for a time at least, only, the chronic kidney 
disease, as evidenced by albuminous urine, with but few other dis- 
orders to deal with, a system of diatetics and general mode of living 
must be followed, the chief object of which must be to throw as little 
work, so to speak, as possible upon them. The action of the skin 
will now be best insured hj moderate exercise ; warm clothing should 
indeed still be used, so as to aid exercise in inducing perspiration, 
and to prevent its too ready suppression. The diet should be light 
and unstimulating. It has been proposed to enjoin an abstinence 
from animal food on the ground of the redundance of azotised matter 
in the blood ; but this plan has not generally been found successful, 
and in general meat or fish may be allowed once a day. A valuable 
article of diet also will be milk, when it suits the stomach; and the 
system may be further supported by farinaceous substances. Spirits 
and strong wines are to be avoided, but light malt liquor is admis- 
sible, as also an occasional glass of light wine. A most important 
aid towards recovery is removal to a warm climate ; a voyage to 
India, round the Cape and back, or to the West Indies, has in several 
instances produced, to all appearance, a cure in cases which appeared 
to have advanced beyond the first stage. 

In the still more chronic cases of the small granular kidney, we 
must bear in mind that the chief dangers are those arising from the 
frequently sudden effects of uraemic poisoning upon the brain, and 
the changes (also the effect of urasmia) in the heart and arteries. In 
this form of the disease we must regulate the diet, and encourage the 
action of the skin much in the same manner as in the last, but we 
must allow but very gentle exercise ; and it is doubtful if a warm 
climate would be desirable. The general tendency in this form of 
the disease may perhaps be not inaptly said to be, to premature senile 
changes, and therefore we must direct our attention to succouring the 
powers of the system by every possible means. The diet should be' 
bland and nutritious, but not highly animalised, and, unless custom 
have induced the necessity, but little stimulants should be used. As 
this form of disease may be connected with a gouty diathesis, we must 
most carefully guard against the retrocession of gout, and if any 
symptoms show themselves in the extremities, they should be 
encouraged. When there is any threatening of head affection we 
may apply blisters, or, if there be heat or throbbing, a little blood 
may be taken by cupping. Failure of the nervous power, as shown 
by tremor or gradual paralysis, may be met by sulphate of zinc. 
When the renal secretion is very deficient, gentle diuretics may be 
employed, amongst which the decoct, scopar. co. of the Pharmaco- 



404 bkight's disease. 

poeia, with nitric aether, may be given ; it is, however, very difficult 
to get duretics of any kind to act. A steady action of the bowels 
must be maintained, and when there is no irritability of the large 
intestines, the compound decoct, of aloes with a little additional 
bicarb, of potass, and about ten grains of rhubarb, will act agreeably. 
If care be taken to relieve the kidneys by acting upon the skin, and 
to avoid all excitement either of the "brain or the organs of circula- 
tion, life may be prolonged for several years ; but such a patient is 
always in jeopardy, and from the different forms of apoplexy to 
which he is liable, as he is also to sudden death from the heart. 



URINARY DEPOSITS AND DIABETES. 405 



XXIII. 

UKINAKY DEPOSITS AND DIABETES. 

"We have already spoken of the symptoms of a stone, or calculus, 
as well as of gravel or sand in the kidneys, or passing thence through 
the ureter into the bladder, as regards the urinary organs ; that is to 
say, as regards the mechanical irritation they produce, considered 
simply as foreign bodies, in which respect the different kinds of cal- 
culus matter pretty closely resemble each other ; but the case is far 
otherwise in regard to their chemical composition, and in great 
measure also as to their physical properties ; and no less so in regard 
to the causes which produce them, and, consequently, the means 
which must be used for their prevention. 

When, therefore, we have reason to suspect the presence of any 
such matters in the urinary organs, or even the tendency to them, 
we examine the chemical condition of the urine, not only once or 
twice, but often, with a view to ascertaining not its condition upon 
one occasion only but repeatedly, that we may be enabled to form 
an opinion of the habit or diathesis of the patient in this particular ; 
and a knowledge of this will enable us to reason not only forwards, 
to the probable character of any sediment or secretion which may be 
in the urinary organs either in esse or in posse, but backwards also to 
several antecedent conditions of the chylopoietic viscera which may 
have led to their formation. 

It is known to every one that fresh urine from a healthy person is 
generally more or less acid, though this may vary from a very 
decided reaction to almost neutrality, the acidity being the greatest 
in urine voided just before meals, and the least when digestion is 
going on. This is generally believed to depend, not upon the pre- 
sence of a pure acid but of super-salts of the alkaline or earthy bases 
which the urine contains. Now, although the stronger mineral acids, 
the sulphuric and the hydrochloric, are both present in the urine, 
those which we should naturally look for in a free state would be 
the uric (or lithic) and the phosphoric, not only from the great abund- 
ance of the former, but also because either would be liable to be set 
free, by the former entering more readily into combination with the 
alkaline and earthy bases which the urine contains : they do not, 
however, exist in a free state in the urine of health, but certain of 
the bases are not perfectly neutralised, and form super-salts with 
those acids ; or, in other words, they form super-urates and super- 
phosphates. 

It is probably upon the presence of super-phosphate of soda that 
the acid reaction of the urine depends, since it is questionable Avhe- 
ther the super -urate is ordinarily present, though the urate of ammo- 
nia exists in great abundance, and is readily soluble in water, and in 
urine in its normal condition. Now this latter salt is, of course. 



406 1>RIC ACID AND URATES. 

readily decomposed by tlie presence of any stronger acid than the 
uric, which, being insoluble, will of course be precipitated, and accor- 
dingly it comes down in the form either of an amphorous sediment, 
or of minute grains, resembling powdered cayenne pepper ; for 
though uric acid may thus be rendered insoluble in the urine, it 
does not generally come down in the shape of crystals, since, as Dr. 
Bence Jones has taught us, the hydrochloric, which is the acid upon 
which excessive acidity of the urine mainly depends, does not imme- 
diately decompose urate of ammonia, the combination in which the 
uric acid exists in the urine, but renders it less soluble, throwing it 
down in the form of an amorphous powder. "We have, then, two 
forms of uric acid deposits, the free crystalline uric acid itself, which 
can only appear when the urine contains a great excess of hydro* 
chloric acid, — and the urate of ammonia, showing itself in amorphous 
sediments, generally of a pinkish fawn or drab-colour, redissolved 
by heating the urine, which the free lithic acid is not : but independ- 
ently of being of limited solubility in cool urine, which is normally 
acid, it may also make its appearance, being thrown down as shown 
by excess of acid from its being actually in greater quantity than in 
perfect health, either absolutely or in proportion to the quantity of 
fluid secreted. In the majority of instances, the precipitate is 
dependent upon both these causes. 

The immediate or chemical cause, then, of the depositions of uric 
acid, is excessive acidity in the urine. The probable cause of this 
acidity is to be found in the stomach, the acidity of which varies, as 
we have seen, inversely as to that of the urine. In cases of extreme 
irritability of this organ, there is, probably, during digestion, a rapid 
secretion of hydrochloric acid ; during this process, the acidity of the 
urine would be diminished, or would altogether disappear ; but after 
a reabsorption of the acid, the urine would become proportionally 
acid ; this shows the fallacy of observations upon the acidity of the 
urine made only once in twenty -four hours, since it is probable that 
at certain times in the day the urine of a person passing free uric 
acid may be alkaline. The chemical cause of the deposit of the non- 
crystallised sediment, the urate of ammonia, is either excess of acid 
or an unusually large quantity of the urates, often both causes com- 
bined. The morbid causes of this condition may be either gastric 
irritation, as in the case of the uric acid crystals ; gout or rheumatism, 
or other febrile disturbance ; or a deficiency in the quantity of water 
proportionate to the solid contents of the urine, as in the case of 
obstruction to the portal circulation. In the two latter conditions 
the urates alone are precipitated, without any crystals of uric acid ; 
but in the former uric acid also is always present if there be a con- 
siderable acidity of the urine. 

The diagnosis of these forms of disease must depend upon the 
examination of the deposits both by the microscope and chemically ; 
the latter, however, when there is the least doubt, is the only means 
to be relied upon. The microscopic appearances of crystalline uric- 
acid present every combination of the rhombic prism, though these 



THEIR CAUSES AND DIAGNOSIS. 407 

may arrange themselves into forms very likely to mislead.* Uric 
acid is destroyed by heating it to a red heat in a platinum spoon, it 
burns in fact. When uric acid is treated with a little nitric acid, 
and then heated to dryness, it becomes of a deep red, which is 
always increased in intensity by the addition of vapour of ammonia. 

The urate of ammonia is, for the most part, thrown down as an 
amorphous sediment ; as regards the test of burning, and of the 
addition of nitric acid, it comports itself like the uric acid ; but there 
is this difference ; — that though both are dissolved by carbonate of 
potass, the Titrate of ammonia evolves ammoniated fumes when the 
solution is heated, which is not the case with uric acid ; and what is 
still more to the purpose, urate of ammonia is readily dissolved by 
heating it in water, which is not the case with uric acid. This last 
test enables us to determine whether urine which obviously contains 
urate of ammonia, contains likewise uric acid, a question which may 
always be answered by heating the liquid, when if it becomes per- 
fectly clear the deposit is urate of ammonia, without uric acid. 

These two kinds of deposit of uric acid require different modes of 
treatment according to their cause. When the crystalline uric acid 
is present, either with or without the urates, the medicinal treatment 
must consist in the exhibition of alkalies, and the dietetic, in abstin- 
ence from acids and all substances likely to become so. For the first, 
the liquor potassae, carbonate of potass, saline draughts of citric acid 
and citrate of potass, and phosphate of soda may be employed ; the 
carbonates of soda and magnesia are sometimes used, but the first is 
open to the objection, that the urate of soda is insoluble ; and the 
latter, that it sometimes forms concretions in the alimentary canal. 
As regards the regimen, we must prohibit the use of vegetable acids, 
and enjoin a very moderate use of substances containing much starch 
or sugar, since they readily form a vegetable acid in the stomach. 
To promote the removal of acid by the skin, and the free evolution 
of carbonic acid by the lungs, is an indication of still greater mo- 
ment ; for this cause moderate exercise should be used. 

The deposit of the amorphous lithates, being dependent upon no 
great excess of acid in the urine, (when unaccompanied by free lithic 
acid,) should not be treated with alkaline remedies, at least not as a 
general rule, since we should rather turn our attention to the disease 
of which they may be symptomatic. When the deposit occurs as the 
consequence of slight dyspeptic derangement, or excesses or irregu- 
larities in diet, a little additional liquid, as an extra glass of water .or 
soda-water, or a gentle diuretic will, as Dr. Bence Jones observes, 
dissolve the urate of ammonia, by increasing the quantity of liquid 
in the urine : whilst we must look to a very moderate diet, and 
moderate exercise, for effecting a cure. But in those diseases in 
which (as we have pointed out) the urates come down through a defi- 
ciency of water to hold them in solution, owing to disease in the course 
of that circuit through which water passes from the intestines to the 
arterial system, diuretics, whether gentle or of a more powerful kind, 

* Bird on Urinary Deposits. 



408 PURPURIC E. 

will "have little or no effect, until we obviate the primary disease, if 
it be possible to do so, or if not, till we have in some degree relieved 
the circulation, by measures adapted to the particular affection. 

In connection with urate of ammonia we may allude to the re- 
markable colouring matter purpurine, which is sometimes present in 
considerable quantities, but never comes down as a deposit unless 
urate of ammonia be also present, which has the property of remov- 
ing the great mass of purpurine from the urine, and assuming thereby 
a purple tint.* Urate of ammonia, thus coloured, varies from a 
pinkish drab or fawn colour to that of a rich carmine ; so deep, 
indeed, is the colour that urine in which it has been suspended has 
not unfrequently been supposed to be coloured with blood; so 
close, sometimes, is this resemblance, that it is necessary to satisfy 
ourselves of the absence of the latter by the appropriate tests. 
It also interferes so much with the solubility of the urate of am- 
monia with which it is united, that long continued boiling is 
necessary to effect its solution ; a familiar instance of this is to be 
found in the pink stain or fur, as it is often called, which adheres 
to the bottom of the utensil, and for the removal of which the house- 
maid is often obliged to have recourse to hot water and soda or 
potass. The brightness of the colour when this deposit is collected 
in a filter, and the fact that alcohol will separate the purpurine from 
the urate of ammonia, by dissolving the former and leaving the urate, 
are sufficient characteristics. In examining urine highly coloured by 
purpurine, care is requisite to avoid confounding it with the muddy 
deposit of uric acid thrown down by nitric acid with albumen. This 
property which purpurine possesses of precipitating urate of ammonia 
gives it considerable importance in reference to urinary calculi, which 
thereby receive strata of urate of ammonia which would otherwise 
have remained dissolved in the urine. It possesses also a further 
pathological importance from its indicating an impediment to the 
free secretion of bile by the liver, or perhaps more correctly the 
purpurine being a more highly carbonised substance than any in the 
urine, is the form in which that principle appears when the kidneys 
take on a supplementary action to the liver, and through the liver to 
the lungs. It does not, as Dr. Grolding Bird remarks, universally 
occur in phthisis ; and the reason of this is, that, as we have else- 
where pointed out, there may be great disorganisation of the lungs 
in phthisis, yet no considerable defect in the decarbonisation of the 
blood by these organs, owing to the diminished quantity of the blood 
itself: but if the lungs have become rapidly obstructed, whether by 
phthisis, capillary bronchitis, or the various other diseases which we 
have shown to produce that effect, purpurine soon appears in the 
urine. 

Oxalate of lime is another deposit of frequent occurrence in the 
urine, chiefly, perhaps, important from its tendency to form concre- 
tions in the kidneys and bladder. Dr. Bence Jones considers it of 
very little consequence in other respects, from its being found in the 

* Dr. Golding Bird, "Urinary Deposits, Philada. ed., p. 158. 



OXALATE OF LIME. 409 

urine of persons in good health, as well as of those in very opposite 
states of disease. Dr. Golding Bird, on the contrary, regarded it as 
indicative of derangement of the general health, and therefore of 
great pathological importance, besides its tendency to form calculi of 
the most painful form. The truth will probably be eventually found 
to lie between these two opinions ; the frequency of its occurrence, 
for which fact we are in the first instance indebted to Dr. Bird, is 
sufficient to awaken our attention to the importance of this form of 
deposit, whilst the fact of its being often found in the urine of healthy 
persons, proves that it does not necessarily indicate any great devia- 
tion from health, though it may point out to what form of diseased 
action the patient in question may be more particularly liable. There 
can be little doubt that a tendency to deposit oxalate of lime is 
associated with an excessive secretion of uric acid and urea from the 
kidneys, that it is often accompanied by great nervous irritability, 
languor, emaciation, hypochondriasis, and want of nervine and phy- 
sical energy, consequent upon a drain upon the system analogous to 
what may be seen in spermatorrhoea and in leucorrhoea in females. 

The diagnosis of this deposit is very simple ; if the urine be allowed 
to stand in a tall glass for about an hour, and the greater part of it 
decanted, the portion remaining at the bottom will be found under a 
half-inch glass to contain minute octohedral crystals. It is a remark- 
able fact that oxalate of lime has a great tendency to alternate in the 
same patient with uric acid or urate of ammonia. 

The treatment of the diathesis, if it may be so called, consists in 
attending carefully to the state of the skin and in regulating the diet. 
Good mutton once a day, or when the appetite admits of it and the 
patient requires support, a slice of cold mutton also at breakfast; 
moderate use of fruit, vegetables, avoidance of pastry, cocoa once a 
day in preference to tea or coffee ; barley water or toast-water, or good 
water itself, for drink, unless the state of the patient seems urgently 
to call for stimulants, when a little weak brandy and water may be 
allowed. Nitric acid, or the nitro-hydrochloric extemporaneously 
prepared may be given, in a bitter infusion, twice or thrice a-day. 
The use, however, of the acids must be carefully watched, as they 
will after a time produce urate of ammonia in the urine ; when this 
begins to be the case they must be discontinued. When there is 
anaemia, tincture of sesquichloride of iron should be employed ; when 
much nervous debility, sulphate of zinc. 

An excess of sulphates exists sometimes in the urine, though it 
does not show itself in the form of any deposit ; the sulphates of soda 
and potass being always present, whatever be the condition of the 
urine; the sulphuric acid may, however, be precipitated, and its 
quantity ascertained, by adding a solution of chloride of barium, 
taking the precaution of adding a few drops of hydrochloric acid to 
ensure the solution of any phosphate of baryta that may be formed. 

Dr. Bence Jones gives the following summary of his observations 
on the occurrence of sulphates in the urine : 

1. That the sulphates in the urine are much increased by food, 
whether it be animal or vegetable. 



410 EXCESSES OF SULPHATES. 

2. Exercise does not produce so marked an increase in the sul- 
phates. 

3. Sulphuric acid, when taken in large doses, increases the sul- 
phates in the urine; in small quantities it produces little or no effect. 

4. Sulphur, when taken, increases the sulphates in the urine, and 
sulphates of soda or magnesia produce the greatest effect upon the 
quantity of sulphate in the urine. 

The phosphates, both alkaline and earthy, are liable to considera- 
ble variations as to the quantity in which they occur in the urine, 
and the latter are often precipitated, producing deposits, and some- 
times forming calculi in the bladder. The fact, however, of their 
being precipitated is no proof of their being present in any unusual 
quantity, since they may exist in even an abnormal proportion, and 
remain dissolved; hence the term phosphatic diathesis, commonly 
applied to the state of the system in which the urine presents these 
deposits, is hardly applicable. The manner in which earthy phos- 
phates are thrown down from the urine is as follows : 

Phosphoric acid is what is termed a tri-basic acid ; it can only 
combine with three equivalents of an alkali or oxide (neither more 
or less) ; but these three equivalents need not be of the same oxide 
or alkali ; and one or two of these equivalents may be oxide of hydro- 
gen or water. Thus we have three phosphates of soda; one equiva- 
lent of the acid with two of water and one of soda; this, called acid 
phosphate of soda, having an acid reaction. Again we have another 
tri-basic salt, in which one equivalent of phosphoric acid is combined 
with one of water and two of soda ; this is the common phosphate of 
soda, which has a slightly alkaline reaction. Lastly, we have a third 
tri-basic phosphate of soda, consisting of one equivalent of the acid 
to three equivalents of soda. This salt has a decidedly alkaline 
reaction; but all the salts are alike tri-basic. The first two exist in 
the urine, but more commonly the acid phosphate, which probably 
gives its alkaline reaction to that fluid ; but neither of these is ever 
precipitated, whatever be the character of the urine, since they are 
highly soluble under all circumstances. The earthy phosphates in 
the urine are the phosphate of lime, which consists of one equivalent 
of phosphoric acid to three of lime, and according to Dr. Bence Jones 
ammonio-phosphate of magnesia. These phosphates are soluble only 
in a fluid having an acid reaction; and the solution of the acid phos- 
phate of soda is sufficient for this purpose; whilst, therefore, the 
urine is even slightly acidulated by this salt, there being no alkali 
or alkaline carbonate sufficient to neutralise it, the phosphates of 
magnesia and lime will not be thrown down; but urine which is 
alkalised from carbonate of ammonia, carbonate of soda, carbonate 
of potass, or the common phosphates of soda, being unable to dis- 
solve these phosphates, they therefore occur as a deposit; hence it 
appears that the so-called phosphatic diathesis, in which these preci- 
pitates occur, is really an alkaline one, since there is not necessarily 
any excess of phosphate present, in point of fact generally the reverse. 
For the method of ascertaining the amount of phosphates present, the 
student should consult Dr. Bence Jones' work on Animal Chemistry 



PHOSPHATES. 411 

and the no less valuable one of the late Dr. Golding Bird on Urinary 
Deposits. 

The following conclusions, drawn by Dr. Bence Jones from a long 
series of observations, if of no other value, are most important as 
disproving a number of very prevalent errors upon the subject. 

1. The variations of the earthy phosphates are so dependent on the 
earthy matter (lime and magnesia) present in the urine, that no 
deduction from them as to the nature or state of disease is probable. 

2. Neither the earthy phosphates nor the alkaline phosphates are 
permanently increased in spinal diseases. 

3. In fevers, and acute inflammations of fibrous, muscular, or car- 
tilaginous tissues, the total amount of earthy and alkaline phosphates 
is not increased. 

4. In chronic diseases in which the nervous tissue is not affected, 
no deductions can be drawn. 

5. Chronic cases of mania, melancholia, and general paralysis of 
the insane gave no results. 

6. In chronic diseases of the brain, and in chronic and even acute 
diseases of the membranes, there is no increase in the total amount 
of alkaline and earthy phosphates. 

7. In fractures of the skull, when any inflammation of the brain 
comes on, there is an increase of the total amount of phosphates. 
When there is no head symptoms, no increase of the phosphates is 
observed, even when other acute inflammations supervene. 

8. In acute inflammation of the brain there is an excessive amount 
of phosphates in the urine. When the inflammation becomes chro- 
nic, no excess of phosphate can be shown to exist in the urine. 

9. In some functional diseases of the brain an excessive amount of 
phosphates is observable ; this ceases with delirium. Delirium tre- 
mens shows a remarkable deficiency in the amount of phosphates 
excreted, provided no food be taken. Where food can be taken, the 
diminution is not apparent. 

It appears that excess of phosphates in the urine is the effect of a 
few, though very few diseases ; but it is not the cause of any, and 
therefore requires no directly remedial measures. 

With alkaline urine, however, the cases is different, since it is not 
only a sign of disease, but also by the phosphatic deposits which it 
produces, is the cause of gravel and calculus. Now, we have stated 
that the carbonate of ammonia will cause these phosphatic deposits 
to occur in the urine, and carbonate of ammonia is a common cause 
of alkalescence of the urine ; but whence comes the ammonia ? This, 
as is now well known, is produced by the decomposition of the urea 
— this urea, which is the principal solid ingredient of the urine, and 
is very prone to decomposition, forming carbonate of ammonia by 
combination with water, thus: — 

Urea = Q H 4 N 2 2 
Water = H 0, 

4 4 



C 9 H fi N ==CL (X +N EL =Carbonate of ammonia. 



412 UKINARY DEPOSITS. 

Healthy urine does not undergo this change till some considerable 
time after its excretion from the body ; but in disease of the mucous 
lining of the bladder, ureters, or pelves of the kidneys, the unhealthy 
mucous, which is secreted, may act as a sort of ferment, inducing 
the change of urea into carbonate of ammonia; but independently 
of this, there are many morbid conditions, some of them lesions of 
innervation, and others generally dependent on a low degree of vital 
power, in which there is either a disposition in the urine speedily to 
undergo this change ; or in the very act of secretion, the elements of 
urea arrange themselves, instead, into the form of carbonate of am- 
monia and water. The most familiar instance of this is that of alka- 
line (ammoniacal) urine, resulting from injuries to the back ; this effect 
being produced, as Sir B. Brodie has pointed out, equally whether the 
injury is inflicted in the lumbar, the dorsal, or the cervical regions. 
The ammoniacal urine thus present in the bladder, no doubt proves 
in its turngan irritant to the mucous lining of that organ, which 
pours out an increased quantity of mucus; the mucus becomes, as it 
is termed, ropy, by the action of the alkali upon it, and thus the urine 
itself becomes ropy. This tough mucus is sometimes mixed up. with 
earthy phosphates, which are deposited; and becomes a nidus for 
the formation of calculi. 

Besides, however, the alkalescence of the urine from carbonate of 
ammonia, it may also become alkaline from the presence of carbonate 
of potass or soda, this being the consequence of an increased secre- 
tion of acid in the stomach (probably through irritability of that 
organ), and this increased acidity at one extremity of the digestive 
process, so to speak, produces a corresponding alkalescence of the 
other. This alkalescence, however, is not constant, occurring almost 
exclusively during the process of digestion. 

We see then that the causes of the phosphatic deposits in the urine 
are complex. (1) They depend primarily upon one of these condi- 
tions, either an excess in the quantity of the earthy phosphates them- 
selves, or on the urine being alkaline ; generally, as in the case of the 
urates, upon both of these conditions. (2) The alkalescency of the 
urine may have a two-fold origin, either, that is to say, from carbon- 
ate of ammonia, produced by decomposition of the urea, or from car- 
bonate of a fixed alkali resulting from irritability of the stomach. 
(3) There may be several conditions favouring the decompo'sition of 
the urea, namely, — disease of the mucous lining of the bladder and 
urinary passages — lesion of innervation, as in the case of blows on 
the loins, and injuries to the spinal column — and general debility of 
constitution, from whatever cause arising, whereby a faulty assimila- 
tion is produced, and the urea formed in the extreme circulation 
tends more rapidly to degeneration to the lower substances in the 
scale of organisation, carbonate of ammonia and water. 

In regard to diagnosis there are two points to be determined ; first, 
the diagnosis between phosphates and other forms of urinary deposit, 
and between phosphates the result of ammoniacal urine, and those 
thrown down by fixed alkalies. The phosphates, which often form 
calculi in the bladder are, the phosphate of lime, and the phosphates 



CAUSES OF PHOSPHATES. 413 

of ammonia and magnesia. They most commonly occnr mixed in 
the same calculus, which is then termed the fusible calculus. The 
phosphate of lime occurs alone as a precipitate, chiefly from indiges- 
tion; the phosphates of ammonia and magnesia chiefly in conse- 
quence of diseased bladder, or of the other causes which have been 
pointed out as rendering the urine ammoniacal. Deposits of these 
salts are always white, unless coloured with blood, soluble in dilute 
hydrochloric acid, and insoluble in ammonia or liquor potassse. The 
phosphate of lime, which, as we have observed, is generally precipi- 
tated with the ammonio-magnesian phosphate, is not so readily 
soluble in very dilute acids as the former, and therefore, when a 
mixec^ deposit of the phosphate of lime and triple phosphate occurs, 
the phosphate of lime is but slowly acted upon when digested in very 
dilute acetic acid, which readily dissolves the magnesian salt. When 
either the triple phosphate or the phosphate of lime is exposed to 
the flame of the blow-pipe it fuses with great difficulty, and not 
until the heat has been urged to the utmost. If, however, the phos- 
phate of lime is mixed with the triple phosphate in about equal pro- 
portions, they readily melt into a white enamel, constituting what 
has been spoken of above as the fusible calculus ; by which property 
these mixed salts can be readily detected in concretions — a charac- 
teristic very available in the examination of gravel and calculi, as 
the two phosphates generally occur together.* In short, the ammonio- 
magnesian phosphates are very readily soluble in dilute acetic acid; 
but the phosphate of lime very slowly so. Both are fused with 
extreme difficulty; but the mixture of the two, which is the more 
common deposit, is readily fusible. 

The physical appearance (says Dr. Bird)f presented by deposits of 
the earthy phosphates varies extremely ; sometimes, especially when 
the triple salt forms the chief portion of the deposit, it falls to the 
bottom of the vessel as a white crystalline gravel. If but a small 
quantity of this substance be present, it may readily escape detection 
by remaining for a long time diffused through the urine ; after a few 
hours repose, some of the crystals collect on the surface, forming an 
iridescent pellicle, reflecting coloured bands, like soap-bubbles or a 
thin layer of oil. 

The phosphates when very abundant will often present the appear- 
ance of thick mucus, from which they may be distinguished by their 
being readily dissolved by the addition of hydrochloric acid : when the 
pus or thick mucus, as not unfrequently happens, is mixed with the 
phosphates, the only means of detecting the latter is by placing a 
few drops of the urine between two plates of glass under the micro- 
scope, when the phosphatic crystals will be easily recognised. 

The microscopic characters are — (1.) Prisms exceedingly well 
defined, with the angles and edges remarkably sharp and perfect, the 
triangular prism predominating, though every variety of termination 
may be present; these consist of neutral triple phosphates. (2.) 

* Dr. Golding Bird on Urinary Deposits, Philada. edition, p. 2-2. 
f Op. citat., p. 223. 



414 UEINARY DEPOSITS. 

Stellated crystals of the neutral triple phosphates, composed of acicu- 
lar prisms cohering at one end. These, though not unlike crystals 
of uric acid, in form, are always colourless, and never present the 
yellow orange of the last deposit. (3.) Penniform foliaceous crystals, 
of the basic salt of lesser portion, as generally taking place out of 
the body. (4.) The phosphate of lime occurs either as an amorphous 
powder, or in roundish particles. 

The next question is as to the different causes of the precipitation 
of the phosphates. When the urine is alkaline from fixed alkali, 
the cause is gastric derangement ; when the urine is alkaline from 
carbonate of ammonia, the cause is metataxis of the elements of 
urea, and may depend either upon organic disease of the urinary 
organs, or upon general constitutional debility. 

The broad distinctions between the characters of these two kinds 
of urine are these. That ammoniacal urine does not at first affect 
blue test paper, but that when the paper has dried it becomes red. 
This is not the case with urine alkaline from fixed alkali. In the 
former kind of urine the alkalescence is constant, in the latter vari- 
able. The former shows prismatic crystals under the microscope, the 
latter, when fresh, only granular deposit. 

In regard to the treatment of this class of disorders, we may first 
dispose of those cases in which the urine is alkaline, probably from 
fixed alkali, and the cause gastric irritation. The treatment of these 
belongs more properly to that of dyspepsia. They are generally 
attended with pains and distension after meals ; the former being 
often of the character of cardialgia, and penetrating through between 
the scapulae, torpid bowels, and not uncommonly depression of 
spirits, languor, loss of appetite, and white tongue indented by the 
teeth. These cases often present an excess of urea, as well as a 
deposite of crystalline or amorphous phosphates. 

The treatment must be rather rational than chemical. Exercise 
and employment, or cheerful recreation, are amongst the best of 
remedies ; to which may be added, the conium and blue pill, twice a 
day, for a few days, and the compound gentian mixture, with 20 
minims of aromatic spirit of ammonia, in the morning. The mer- 
curial should not, however, be continued for more than three or four 
days ; but the aperient tonic may be persevered in. The bismuth 
with acid or with the conium may be used ; but above all things 
moderate diet and exercise. 

The ammoniacal urine may be the result either of general debility, 
of disease or injury to the spine, or of disease of the bladder. In the 
first of these cases we must, as before, look mainly to the general 
condition of the patient, more especially to that of the nervous sys- 
tem. Such patients are often those who have undergone much wear 
and tear of body or mind, or both, or who have injured their consti- 
tutions by excesses. And here, as before, our treatment must be 
mainly directed to the general health, availing ourselves of the state 
of the urine, as a help to the knowledge of its condition. These 
cases are often attended with an excess of urea in the urine, the effect 
perhaps of an excessive waste of the tissues. In them, as in the for- 



URINARY DEPOSITS. 415 

mer cases, we must have recourse to the tonic aperient, or if the 
bowels be irritable we may employ the infusion of cascarilla or 
columba instead of the mixture of gentian and senna. If the tongue 
be coated, the pill of hydrarg. cum cret. and soda (F. 77)* may be 
used every second or third night, for a short time ; but any prolonged 
use of mercury is to be rigidly abstained from. And when the ner- 
vine depression has subsided sufficiently to enable us to dispense 
with the ammonia, the nitric or nitrohydrochloric acid may be given 
in the bitter infusion, and at the same time the nervous power may 
be improved, and the nervine irritability relieved by a combination 
of sulphate of zinc with extract of henbane, or extract of hop. The 
zinc may be first given in grain doses, three times a day; and the 
dose may be gradually increased to four or five. Moderate diet — 
mutton once a day, and two or three glasses of sherry — avoidance of 
strong tea or coffee ; cocoa for breakfast where it agrees is to be 
given. 

In those cases, again, in which, with phosphatic sediment in the 
urine, there is a marasmus and much nervous debility, great anxiety 
of countenance, a red tongue, thirst, and symptoms in general closely 
allied to those of diabetes, and probably referable to shock or injury 
to the spine, and in which too the deposit is chiefly phosphate of 
lime, we must pursue the same tonic treatment, combining bismuth 
with the zinc; and besides this, endeavouring to allay the nervous 
irritability. For this purpose, Dr. Prout and Dr. Golding Bird con- 
cur in recommending opium, or what is better, the salts of morphia. 
Dr. Bird recommends from one-third of a grain to half a grain of the 
acetate to be given three or four times in the twenty-four hours, and 
persevered with for some weeks. 

In some cases the constitutional symptoms are not very urgent; 
for this reason the deposit attracts less attention, and the formation of 
a calculus may ensue. To obviate this, mineral acids have been pre- 
scribed, but it is doubtful if any of them, except the phosphoric, ever 
reach the urine, unless given in doses which are hardly safe. But 
the nitric, though it may not act chemically upon the secretion, 
often corrects its alkalescence, probably by its tonic action upon 
the stomach, and is less likely to cause irritation. 

In the last class of cases, in which the urine is ammoniacal from 
mucus secreted by diseased bladder, our attention must be directed 
to the primary cause, and our remedies to obviating as much as 
possible every cause of irritation. The diet should be light and 
unstimulating, demulcent drinks may be employed, and the nitric or 
nitrohydrochloric acid administered; care must be, from time to 
time, taken to ascertain that the urine is really ammoniacal, and it 
must not be hastily presumed to be so merely by its odour. When 
there is much restlessness and uneasiness opiates may be employed, 
and a suppository of ten grains of pil. sap. co. will often give great 

* (77) R. Hyd. cum Cret, 

Sodas Carb. essic. lia, gr. ij. 
Extr. Hyoscyam. gr. iv. Misce. 
Ft. Pil. ij. 



416 DIABETES. 

relief. The washing out the bladder from time to time with warm 
water, should also be steadily persevered in. 

DIABETES. 

Diabetes is a disease about the true nature of which there was 
formerly, and still exists, much obscurity. Its cause used to be 
referred to the kidneys, it was thence transferred to the stomach ; it 
then acquired a temporary occupation of the cerebellum ; and is now, 
whether permanently or not, placed in the liver. Still, as the one 
prominent symptom is the remarkable change in the renal secretion, 
we have connected it with the urinary deposits. 

The invasion of diabetes is generally very gradual. The patient 
commonly feels weak and languid, and complains of thirst, and it 
may be that he notices that his urine is becoming very abundant ; 
though in a very large proportion of cases, patients do not mention 
this symptom till questioned concerning it. Subsequently the patient 
loses flesh and strength, though his appetite is often good, sometimes 
excessive. He complains much of thirst, and of dryness of the fauces ; 
the breath has a sweetish odour, or, if the expression may be used, 
a sourish sweet one ; the tongue is clammy, red, and raw-looking at 
the edges, with sometimes a whitish-brown streak down the middle. 
With the loss of bodily strength, that of the mind also fails. The 
patient loses the power of continued attention, becomes infirm of 
purpose, irritable, anxious, or desponding. The symptoms in the 
majority of cases slowly advance, and, after a period of months, or 
sometimes years, he gradually sinks exhausted ; or phthisis rapidly 
develops itself, and speedily puts an end to his life. Sometimes there 
is sudden death. 

The one characteristic symptom is the presence of sugar in the 
urine; the prominent one, sooner or later, is the excessive quantity 
of that secretion; hence its name, diabetes, from 8tai3an>G>, "I pass 
through," though the connection between the excessive flow of urine, 
highly charged with sugar, and the other symptoms, is not at first 
sight very apparent. Into the extended investigation connected with 
this subject it is not our province to enter, we therefore content our- 
selves with a very brief summary of the facts which have been 
ascertained. 

A considerable proportion of sugar is contained in the food we eat, 
but in addition to this, a larger quantity is produced by the trans- 
formation of the amylaceous substances which enter so largely into 
most articles of vegetable diet ; which transformation is effected by 
the pancreatic secretion. This sugar is dissolved and taken up and 
conveyed by the veins from the intestines into the portal vein, dis- 
tributed through the liver, whence it is brought in the course of the 
circulation to the right ventricle; but in its passage through the 
liver it is found to have undergone a remarkable change : this hepatic 
sugar, or glucose, though isomerically the same, is now found to be 
capable of being oxidised in the lungs, so that it is made subservient 



ITS N A TUBE. 417 

to the purposes of forming carbonic acid, in the generation of animal 
heat, and also, in all probability, of nourishing the non-nitrogenised 
tissues, fat, cartilage, &c. We say that the sugar has acquired the 
remarkable property of being thus changed in the lungs, for ordinary 
sugar will not be acted upon in the lungs, neither will that which 
has been changed in the liver, unless it be dissolved in perfect blood, 
that is to say, that if common sugar be exposed in the blood to the 
air in the lungs, it remains unchanged ; and so with the sugar taken 
from the blood in the right ventricle, if the blood in which it is ex- 
posed to the air in the lungs have been deprived of its fibrine, So 
that two things are essential. The action of the liver, and perfect 
blood for a solvent, in order that the sugar may be fitted for its pur- 
poses in the animal economy. Now, in diabetes, the sugar is un- 
changed in the liver, and therefore it remains unchanged in the lungs, 
the consequence of which is, that being unfitted for the purposes of 
nutrition or combustion, it remains in solution, and is eliminated 
from the blood by the kidneys, whose ofhce it is to remove from the 
blood all soluble matters not capable of serving any further purpose 
in the system, which substances act as stimulants to those organs, 
and promote the flow of urine ■ * 

From what has been just stated, it must be very easy to understand 
the subsequent phenomena of diabetes, namely, the failure of nutri- 
tion, the wasting, the hunger, the thirst, the profuse diuresis, the 
sugar in the urine, the saccharine smell of the breath; but of the 
nature of the lesion which prevents the healthy action of the liver 
upon the blood, we know nothing. It has indeed been ascertained, 
that sugar was present in the urine of animals in whom the fourth 
ventricle of the brain had been irritated, and hence it was supposed 
that there was the origin of the malady ; but the observations of Dr, 
Pavey have shown that the sugar has, under such circumstances, been 
duly acted upon in the liver, and that it is not diabetic or morbid 
sugar which has thus found its way into the general circulation, but 
only an excess of glycose, or sugar of the hepatic cavse. 

The diagnosis of diabetes depends upon the detection of the sugar. 
This may be discovered as follow : — To a small quantity of the urine, 
in a test-tube, add about half its bulk of liquor potassae, then boil for 
about two minutes over a spirit-lamp. If sugar be present, the urine 
will assume a rich brown colour; this is a very convenient test for 
clinical purposes; but in some rare cases it may mislead: in all 
doubtful cases, the Trommer's test, of the sulphate of copper and 
liquor potassae should be employed. 

Another sign of diabetes is the high specific gravity of the urine, 
which may be as high as 1050, or more; whenever it is abundant, 
and 1030, or near it, we may suspect diabetes; but we are not to 
overlook the possibility of diabetes without very abundant urine; 
such cases have occurred, and perhaps are more liable than others to 
terminate suddenly. 

* For most of the above we are indebted to the researches of M. Bernard and Dr. 

Pavey. ** 

27 



418 TREATMENT OF DIABETES. 

The treatment of diabetes, from the secresy of the nature of the 
disease, must be obscure and unsatisfactory. The use of amylaceous 
and saccharine articles of food seems to be contraindicated, and they 
do, except in very small quantities, increase the flow of urine, and 
consequent emaciation. But patients will not, or rather cannot, 
endure the restrictions sometimes imposed. Most vegetables are 
objectionable, except the cruciferous plants; malt liquor is to be 
shunned ; bread, and potatoes, and turnips, sparingly used. Let the 
patient have tea or coffee, with plenty of milk, a rasher of bacon, 
and a little toasted bread. For dinner, beef or mutton, game or fish, 
with greens or spinach, and Italian maccaroni boiled in milk. Let 
him drink a little brandy and water. He may have some tea, with 
a little well-toasted bread in the evening ; and as he will want some 
supper, he may have a mutton-chop with maccaroni, or a mess of 
maccaroni and milk. Of medicines we know of none that have any 
direct control over the disease. Some years ago, the author recom- 
mended the use of ammonia in considerable doses, and although the 
chemical theory upon which that recommendation was based has 
since proved to be erroneous, the remedy has certainly been found 
useful by the late Dr. Golding Bird and others, as well as by the 
author. He has generally given the annexed form (F. 78).* The 
cod-liver oil may be given at the same time about twice a-day; 
rennet has been recommended, as has also pepsine, but the author 
has obtained no result from them. The fixed alkalies are not with- 
out good effect : and a course of liq. potassse and taraxacum certainly 
deserves a trial. 

When the urine is very abundant, about three or four minims of 
laudanum may be added to each dose of the ammonia mixture ; and 
about five grains of Dover's powder given at night will promote per- 
spiration. The patient should take moderate exercise, and his mind 
should be engaged either by a moderate attention to business, travel- 
ling, or light reading. As the bowels are apt to be constipated, a 
little castor-oil may be given from time to time. 

* (78) R. Ammon. Sesquicarb. 9 ij. 

Infus. Cascarillse, ^ viij. Misce. 
From 3 ij to ^ i. to be taken every fourth or sixth hour. 



INFLAMMATOKY DISEASES OF THE BRAIN. 419 



XXIY. 
INFLAMMATOBY DISEASE OF THE ENCEPHALOK 

The contents of the cranium, like those of the other cavities of 
the body, are liable to attacks of inflammation, but it unfortunately 
happens that, important as are those affections, there are none of 
which the diagnosis is attended with greater difficulties. These inflam- 
mations have been by most authors included under the term phreni- 
tis, though some have restricted this term to inflammation of the 
membranes, commonly known as meningitis, whilst inflammation of 
the substance of the brain has been described as cerebritis, a barba- 
rous word for which, nevertheless, we are in want of a substitute. 
Whilst, however, it is highly convenient for the purposes of patholo- 
gical anatomy to restrict the terms meningitis and cerebritis to 
inflammation of the membranes and the cerebrum respectively, it is 
perhaps more expedient for the purposes of practical medicine to 
retain the term phrenitis in its original signification of inflammation 
of the encephalon ; and the reason why we would do so is, that, not- 
withstanding the careful observations of Abercrombie and others, 
we are not as yet in a position to speak of the two diseases as capa- 
ble of separation in practice, however distinct they may be in their 
anatomical condition. By phrenitis then, or encephalitis, we wish to 
express a group of anatomical changes, which, as a group, are allied 
to a certain class of symptoms, but which symptoms cannot at 
present be individually connected with corresponding anatomical 
changes; just as we might have spoken of thoracic inflammation 
generally, before the introduction of auscultation, as including a 
variety of anatomical changes, and presenting a large group of 
symptoms which we were unable upon the instant to connect seve- 
rally with the appropriate pathological changes. 

The inflammatory appearances to which we refer are — 

1. Thickening or opacity of the arachnoid, effusion of lymph or 
pus between the layers of the arachnoid, or between the attached 
surface of that membrane and the pia mater. 

2. Softening of the substance of the brain; the softened substance 
being sometimes of a red colour, constituting the ramollissement- 
rouge of the French authors, or it may be of a yellowish colour, 
sometimes from infiltration of puriform matter, at others from change 
in the red corpuscles of the blood. Effused blood may sometimes 
have been the cause of the disorganisation, but there is equal reason 
to believe that in many cases its presence has been the effect. Ano- 
ther form of softening is simple loss of cohesion without change of 
colour. 

3. The formation of circumscribed abscess in the cerebral matter. 

4. Induration, with increased vascularity of some portion of the 
cerebral matter. 



420 SYMPTOMS OF PHEENITIS. 

The symptoms of phrenitis present almost as great variation as do 
the morbid appearances. 

In the best marked cases of inflammation within the cranium we 
have, in the first place, fever of a decided character but not more 
violent than in some other forms of febrile disease, perhaps hardly 
so much so. This is followed by acute shooting pain in the head, 
sickness, intolerance of light and sound, generally with a contracted 
pupil, particularly in the most acute cases and where the membranes 
are involved. The pulse is firm, not hard, often rather sharp, seldom 
peculiarly frequent, sometimes slower than natural. The skin rarely 
very hot or dry. These may be regarded as the general symptoms 
of commencing inflammation within the cranium, which, if not 
speedily removed, are generally followed by others, which indicate, 
with some degree of probability, though by no means with any 
approach to certainty, the particular tissue of the encephalon, or, it 
may be, the part of the brain involved. Thus there may be delirium 
often coming on in paroxysms, or partial and temporary loss of 
recollection, convulsions, strabismus, with dilatation of the pupils, 
sometimes of one only, or there may be increased contraction, some- 
times blindness more or less complete, partial paralysis, which is 
sometimes temporary. These symptoms are generally terminated 
by coma more or less profound. The pulse, which, at the superven- 
tion of the second series of symptoms, generally becomes slow, 
increases in frequency at the latter stages, and at last is generally 
characterised by extreme rapidity. The bowels, especially at the 
commencement, are commonly torpid, and acted upon with great 
difficulty, and the urine scanty. The tongue at first is generally 
whitish, not exactly dry, but rather more so than in health. 

As a general rule it may be laid down that convulsion is symp- 
tomatic of inflammation of the membranes rather than of the sub- 
stance of the brain, and paralysis, especially when partial, belongs 
more to the latter affection. In inflammation of the membranes the 
pupils are more contracted, the intolerance of light and sound greater, 
the pulse quicker, and the fever generally of a more active charac- 
ter. In inflammation of the substance of the brain, on the other 
hand, we have as frequently dilated pupil, paralysis, slow pulse, and 
a greater tendency to typhoid symptoms. To the above rules there 
are certainly exceptions, and consequently, though there exists a 
great variety in the symptoms in different cases of encephalic inflam- 
mation, we are as yet unable to account for them by the particular 
tissue affected. 

Cerebral inflammation, especially of the membranes, may be ex- 
cited by the ordinary causes of inflammation, as, for instance, expo- 
sure to vicissitudes of temperature, and also to the direct solar ray 
in hot seasons or in hot climates. It may also be induced by what- 
ever powerfully influences the circulation within the cranium, 
whether affecting the blood itself or its moving powers. Thus it 
may arise from mental anxiety or excitement, as well as from the 
excessive use of spirituous liquors. It may also be induced by pois- 
ons in the blood, whether generated in the system, as in uraemia and 



DIAGNOSIS. 421 

some forms of jaundice, or derived from without, as those of the 
exanthemata. Disease of the arteries may also give rise to it, though 
not generally of an active character, and it may be brought on by 
delirium tremens and rheumatism. External injuries and disease of 
the bones of the head are among the most common causes of cerebral 
inflammation, and amongst these we may particularly notice disease 
of the petrous portion of the temporal bone from otitis. 

The diagnosis of phrenitis is highly important, but no less perplex- 
ing. It is, however, a great assistance to bear in mind that there 
are three diseases with which it is more particularly liable to be 
confounded, namely, fever, either continued or eruptive, acute 
mania, and delirium tremens ; and, as Dr. Addison well remarks, the 
difficulty is the greater, as each of these diseases is apt to be accom- 
panied by more or less inflammation of the brain or its membranes. 
From ordinary fever it may commonly be distinguished by there 
being less oppression, and by the delirium being generally more vio- 
lent and earlier in its appearance, and by the pulse being sharp and 
more commonly irregular, and the skin less hot than in the com- 
mencement of fever ; though, on the other hand, there do occur cases 
in which the fever is more marked, and the local symptoms less 
severe than in well-defined cases of phrenitis, the pulse being soft 
and not irregular, and these cases certainly do for some days remain 
involved in the greatest obscurity until some more decided (though 
often partial) effects of cerebral lesion begin to show themselves. 
Sickness, again, though a very general symptom of cerebral inflam- 
mation, is sometimes wanting, and, on the other hand, it is not un- 
common at the commencement of fever, especially the exanthemata. 
It is, however, fortunate that those cases which most resemble fever 
at the commencement are precisely those which are the least bene- 
fitted by active antiphlogistic measures. 

From delirium tremens the disease may generally be distinguished 
by the harder pulse and drier skin, the skin in phrenitis being less 
dry than in fever, but much less moist than in delirium tremens. The 
scanty urine and the whiter and drier tongue, will also greatly assist 
the diagnosis. 

From acute mania, phrenitis may be distinguished by the disorder 
being in the former almost entirely mental, with little or no evidence 
of derangement of the general health, with the exception of more or 
less disorder of the digestive functions. The delirium is also more 
apt to occur in paroxysms, in which, indeed, the pulse undergoes 
some acceleration, but seldom or ever to the same extent as in those 
forms of phrenitis which are attended by active delirium. 

From hysteria the diagnosis of this, like almost every other disease, 
may be difficult; and here, as in mania, we must be guided by the 
sharpness, frequency, and irregularity of the pulse, which are for the 
most part wanting in hysteria. The disturbances of the uterine func- 
tions must also be taken into account, though it must not be forgotten 
that suppressed menstruation may induce active phrenitis. 

The cephalalgia of dyspepsia may become so intense as to give rise 
to the suspicion of inflammation of the brain, but in the former there 



422 PEO GNOSIS. 

is more obvious disturbances of the digestive organs. The diagnosis, 
however, sometimes requires great care and attention to the symp- 
toms of phrenitis above noticed, and the more so, as in dyspepsia, 
though the pulse is rarely much accelerated, it may become irregular. 
Inflammation of the nervous centres may certainly give rise to 
pains very similar to those of rheumatism, and what is more, it is by 
no means impossible that it may actually give rise to such pains, 
accompanied by swellings closely resembling those of acute rheu- 
matism. The absence of these swellings will, in the majority of 
cases, assist us in our diagnosis ; but when they do occur, which is 
but rarely, and perhaps more commonly in connection with disease 
of the spinal chord than of the brain, the diagnosis becomes in the 
highest degree obscure, until some decided symptoms of nervine 
lesion beo-in to manifest themselves. 

o 

The prognosis of all forms of cerebral inflammation is essentially 
doubtful, and in the more insidious cases, and those especially which 
have been overlooked at the commencement, unfavourable. 

A considerable proportion, however, of severe cases, and those in 
which the symptoms are most clearly marked, recover under active 
antiphlogistic treatment. Of such measures the most important are 
bleeding and purging. In all well marked cases blood should be 
drawn in the first instance from the arm, according to the state of the 
pulse ; and in the more doubtful cases, and where the pulse is soft, we 
should administer an active aperient; and unless there be decided 
contra-indications from the state of the pulse, apply cupping-glasses 
either to the nape of the neck or behind the ears. Next, and perhaps 
hardly next in importance to abstraction of blood, is the energetic 
use of purgative medicines. The bowels in most cases of acute cere- 
bral inflammation are obstinately constipated, from a defect, possibly, 
of innervation; therefore, both to overcome this condition, to relieve 
the circulation, and it may be to produce a revulsion, active purga- 
tives are required. These remedies should be exhibited from the 
first, and need not interfere with the other depletory measures. 
Three or four grains of calomel, with twelve or sixteen of pil. coloc. 
co. should be administered just before or after the first bleeding, and 
this should be followed, in about three hours, by one of the more 
active cathartic draughts, and should this not operate speedily, the 
colocynth and calomel may be ag:ain administered, and if the bowels 
are not freely acted upon, a cathartic injection (F. 79).* After the 
action of the bowels has been established it should be freely main- 
tained by repeated doses of calomel, about two or three grains every 
four hours, and the mixture of magnesia, with the sulphate in the 
intervals ; and the action of these may be further promoted by a tere- 
binthinate enema. The purgatives must be steadily continued until 
the symptoms subside, unless there be such exhaustion as to forbid 
their continuance; "for," says Dr. Abercrombie, "my own experience 

* (79) R. Pulv. Jalapse, 3 ij. 

Infus. Sennae co. Oct. ss. 
Decoct. Avenae, Oct. ss. Misce. 
Ft. Enema. 



TKEATMENT OF PHEENITIS. 423 

is that more recoveries from head affections of the most alarming 
aspect take place under the use of very strong purging than under 
any other mode of treatment." When not contraindicated by the 
irritability of the stomach, antimonials are of service, by diminishing 
the force of the circulation, and perhaps also by their action upon the 
capillaries. Under these circumstances we may in the mixture for 
the carbonate of magnesia substitute a small quantity of tartar-emetic 
as follows (F. 80).* 

At the commencement of the disease the powerful application of 
cold to the head is often of great service. This, in general, is best 
effected by means of ice in a bladder, and should be persisted in as 
long as there is any disposition to undue heat of the scalp, or in- 
creased action of the carotid arteries. Its application also requires 
attention on the part of nurses and attendants, since if it be not 
steadily employed there is apt to supervene a reaction which may be 
injurious. 

The application of blisters, in the early stages of this, as of all 
other inflammations, is objectionable, but after the activity of the 
disease has subsided, and there is threatened coma, they may be used 
on the head and upper part of the spine. The generally very small 
quantity of the urinary secretion would seem to indicate the use of 
diuretics, and of these, the digitalis is perhaps the most appropriate, 
from its effect in controlling the action of the heart. To the use of 
mercury we have before alluded, but chiefly with reference to its pur- 
gative action, and doubtless it is upon this that its beneficial action 
mainly depends. There are, however, many practitioners of very 
high authority who rely much upon its specific action in this disease, 
and there can be no doubt that many cases have begun to improve 
just at the time that the gums were becoming tender, and to promote 
this object they recommend inunction, in addition to its internal 
administration. This is a practice of which it may be said, that it 
does not interfere with, but rather aids other modes of treatment ; 
and that, if the patient survive long enough to be endangered by the 
effusion of lymph, or serum, it has a tendency to prevent these con- 
sequences; but when employed, it must not be in such a manner as 
to interfere with its purgative action, under the idea that its specific 
effect may be lost by its running off' by the bowels, since whatever 
may be the benefits derived from the specific effects of mercury, they 
are— when there is undoubtedly active cerebral inflammation — second 
to those which may be obtained by relieving the circulation through 
the medium of the bowels, and as far as possible by the kidneys at 
the same time. On the other hand, too, it must be borne in mind, 
that the same principle for which we have contended in the treat- 
ment of pneumonia, applies also in the case of phrenitis, namely, that 
when the inflammation is of low form, and the powers of the system 
reduced, so as to produce a tendency to disorganisation, this tendency 

* (80) ft- Mag. Sulphat £ iss. 

Antim. Pot. tart. gr. j. 
Aq. Menth. vir. ^ vj. M. 
A spoonful to be taken every fourth or sixth hour. 



424 HYDEOCEPHALUS. 

is much aggravated by mercurial action : and it is by no means im- 
proper in such cases, when the pulse is soft, the pupils dilated, and 
the skin perspirable, to administer stimulants, carefully, however, 
watching their effects; ammonia is that which we should try first, if 
the bowels prove to be relaxed, and the urine not scanty, in com- 
bination with the infusion of serpentaria, and afterwards wine may be 
allowed. We do not, however, mean to say that mercurial prepara- 
tions are in such cases to be entirely set aside, for the exhibition of a 
grain of calomel two or three times a-day, may have the effect of 
keeping up a sufficient secretion from the liver, but what we mean is, 
that it is not necessary or expedient to push it to salivation. 

The acute hydrocephalus of children is a disease which combines all 
the variety of symptoms above stated, and many of the anatomical 
changes which have been there described, though it has received its 
name solely from the effusion of fluid into the ventricles, which almost 
always takes place when it is sufficiently protracted ; notwithstanding 
that it may prove fatal before any such effusion occurs. The appear- 
ances found on dissection are, in a great majority of instances, effusion 
of serum (with very little albumen) into the ventricles of the brain, 
with a dryness of the surface, sometimes explained by the closure by 
lymph of the opening into the fourth ventricle. These appearances, 
with the exception of the last, which is by no means constant, are not 
in themselves certain proofs of inflammatory action, "but as we find 
in a large proportion of cases which during life have presented the 
symptoms under consideration, the unequivocal marks of inflamma- 
tion co-existing with the effusion into the ventricles, and sometimes 
existing without it : and as we find also that the chief symptoms in 
those undoubtedly inflammatory, are just the same as those which 
present on dissection the effusion only, we can have no reasonable 
doubt that the effusion, when preceded by those symptoms, is to be 
regarded as an effect of a diseased action, either so truly inflammatory, 
or so nearly resembling inflammation, as to demand the same prac- 
tical consideration." ■ 

This reasoning is not, however, entirely unexceptionable, since the 
majority of the symptoms are referable, mainly, to the disturbance 
or suppression of the functions of the brain ; and since it is in accord- 
ance with the principles already laid down to believe that they would 
be nearly similar, whether that suppression or irritation arose from 
the effect of inflammatory action, or from structural change indepen- 
dent of such action, or even as a purely nervine disease, without any 
change whatever cognizable by our senses ; unless, indeed, it can be 
shown that there are in all cases the symptoms which belong, in 
general, to inflammation, independently of the part affected. And 
whether this be conceded or not, it must be admitted that cases of 
hydrocephalus present a great variety as regards the activity of the 
disease, and the signs of inflammatory fever ; the most probable con- 
clusion seems therefore to be, that in the majority of cases the disease 
is of an inflammatory nature, though this inflammation is rarely of 
a very active or sthenic character, and arising generally in subjects 
of a tuberculous or strumous diathesis : but that in such subjects an 



\ 

SYMPTOMS AND CAUSES. 425 

effusion passive, or nearly so, accompanied by softening of the cen- 
tral parts of the brain, may take place without any inflammatory 
action, or that of so low a character as hardly to deserve the name ; 
and the appearances on dissection are often such as lead to the belief 
that some of these changes have preceded any of the inflammatory 
symptoms, and that the inflammation has occurred as a consequence, 
rather than a cause, as in the case of intercurrent pneumonia in 
tuberculated lungs. 

The symptoms of this disease are generally of an insidious charac- 
ter, in which respect, it resembles diseases having their origin in 
some defect of the constitution, inducing a liability to a plastic, or 
caco-plastic deposits, rather than those of a truly inflammatory 
origin. A child, often of a strumous family, and generally with a 
large cranium, or of a very excitable or restless disposition, is 
observed to be more than usually irritable, turns from the light, and 
not unfrequently has an increased appetite for food; the bowels 
generally are confined, and the urine scanty ; the child often appears 
languid, sometimes drowsy, and is disposed to lay its head on its 
mother's or nurse's lap ; if old enough to make its feelings known, it 
complains of giddiness, or appears apprehensive of falling, and refers 
its uneasy feeling to the back of the head, which is often drawn back- 
wards when the child lies down to sleep ; the pulse is frequent, the 
breathing hurried, and the sleep is disturbed by starting or scream- 
ing. These symptoms, which constitute those of what may be 
termed the first, or premonitory period of the disease, are sometimes 
so slight as to be overlooked, though in some instances they are per- 
haps altogether wanting, and the pain in the head, with more active 
symptoms, comes on suddenly upon a state of apparent health, con- 
stituting what is commonly termed the second period of the disease. 

In the second period there is severe pain in the head, with scream- 
ing and knitting of the brows, intolerance of light and sound, with 
increased heat of scalp, with throbbing of the carotids. There is 
often strabismus, and the pupils are generally contracted, sometimes 
unequally so, and occasionally they may be dilated, though probably 
this latter condition belongs properly to the next period of the dis- 
ease. There may be sudden convulsions; the hearing is painfully 
acute; there is frequent vomiting; the bowels are obstinately con- 
fined, but the abdomen is flat; the urine scanty; there are, in the 
cheeks, alternations of vivid flushings and death-like paleness. 
There is generally great restlessness, and the child requires to be 
continually moved, or taken into the arms when awake ; in sleep 
there is constant moaning and grinding of the teeth. At this period 
of the disease, we may have sudden and very great variations; 
thus, a day on which all the symptoms appear to have been much 
aggravated, may be followed by one in which they seem almost 
entirely to have subsided; but this appearance of improvement, or 
almost of recovery, is most fallacious, and may be followed by a day 
of still greater excitement, and this alternation may recur for a 
period of several days. It sometimes happens, too, that the pulse 
sinks suddenly to the natural standard, a change which is often pre- 



426 ACUTE HYDEOCEPHALUS. 

monitory of the supervention of the third period, or that of coma, the 
invasion of which is commonly gradual : it is interrupted by scream- 
ing, convulsions, rolling of the head, and jactitation of the limbs. 
The pupils, during this period, are almost always dilated, and un- 
affected by light, the sight appears to be imperfect, and the cornea 
becomes dim; the pulse again becomes very quick, the teeth are 
clenched, the countenance loses all expressiveness, the evacuations 
are passed involuntarily and frequently; there is more or less par- 
alysis before the fatal termination, which is generally preceded by 
some severe convulsive attacks. 

We have already alluded to the fallaciousness of rapid apparent 
amendment in this disease ; but on the other hand, we must not for- 
get that after the coma has been apparently established, and death 
seems from hour to hour imminent, the patient will pass gradually, 
or, in some cases, almost suddenly, into a state of permanent conva- 
lescence. 

The causes of hydrocephalus resolve themselves into two classes, 
the constitutional and the extraneous. The constitutional consist 
almost entirely in the scrofulous or strumous diathesis. Infancy and 
childhood being, as we have elsewhere pointed out (p. 112), the 
periods of life at which this diathesis is most prone to manifest itself 
in the encephalon. In addition to the period of life and the stru- 
mous diathesis, the circumstance or condition which induces the 
greatest susceptibility of this disease is any more than ordinary 
activity or excitability of the brain ; hence the remark not uncom- 
mon in families who have suffered from this fatal malady, that it is 
generally the most lively and intelligent children who have been 
carried off by it. 

These conditions may coexist to such a degree that the disease 
may appear to originate spontaneously, without any immediate cause. 
Yet it is most commonly induced, even in the predisposed, by some 
circumstance or accident disturbing the circulation generally, or par- 
ticularly any that excites or stimulates the brain, and thereby increases 
the activity of the cerebral circulation. Of these, the most frequent 
are exanthems or other febrile diseases (not to mention that the state 
of debility which follows them often increases the liability to hydro- 
cephalus, though it may not be sufficient to set it up of itself), teeth- 
ing, gastric disturbances, and confined or disordered bowels. Mental 
excitement, and over-exertion of the intellectual faculties, as in exces- 
sive study, and the two great emulation which some of our schools, 
even for children, encourage, often induces or accelerates it. 

The diagnosis of hydrocephalus is often almost as obscure as it is 
important; in young girls it may be sometimes simulated by hys- 
teria, in those of both sexes by phrenitis, and in young children by 
infantile remittent. The diagnosis of hydrocephalus from those dis- 
eases with which it may be confounded, and which have their origin 
in the digestive organs, rests mainly upon the more decided reference 
of all the disorders, feelings, and actions to the head. Thus we have 
from the first irritability or drowsiness, knitting of the brows, aver- 
sion to light, disordered vision, or excessive sensibility to sound ; to 



DIAGNOSIS AND PROGNOSIS. 427 

which may be added, altered disposition, great irregularity, often 
slowness, in the pulse, costive bowels, but without tumescence of the 
abdomen, and scanty nrine. In subjects approaching the period of 
life in which we should expect phrenitis rather than hydrocephalus, 
the question as to which class any particular case in question may 
belong is one rather of names than realities, since the forms of dis- 
ease may merge so insensibly into each other that it is next to 
impossible to draw the limit ; but it is a real and vital question as to 
whether the case is one of the more active and sthenic inflammation 
to which the term phrenitis is more properly applied, or of the stru- 
mous and more disorganising hydrocephalus — a distinction not unlike 
that between pneumonia and phthisis. The age and diathesis of the 
patient, the greater or less rapidity of the disease, the contracted or 
passive pupil, the sharpness of the pulse, may help to decide whether 
the disease approaches to the more or less active affection. 

The prognosis of hydrocephalus is commonly stated to be gene- 
rally unfavourable. It would perhaps be nearer the truth to say 
that it is essentially so, and can only be said to be doubtful so long 
as the diagnosis is so likewise; and the reason is probably this: — ■ 
that hydrocephalus being a disease almost always of a strumous or 
disorganising character, beginning in the central parts of the brain, 
which we know admit of a much greater amount of injury being 
inflicted upon them without their manifesting any well-marked signs 
of such injury, than do the more superficial parts of the organ; we 
can readily believe that disease of this character may have produced 
an almost irreparable amount of mischief before it could have 
extended itself to the surface, that is to say, before it could have 
manifested its most characteristic symptoms; and in a question of so 
much difficulty as that between hydrocephalus and the more active 
though less certainly fatal disease of phrenitis, affecting chiefly the 
membranes, we may always give the patient the benefit of the doubt; 
though this doubt will be greatly lessened by a knowledge of family 
predisposition, or evident signs of the strumous diathesis ; yet where 
the diagnosis . is rendered pretty certain by the subsequent progress 
of the disease, we must not lightly be induced to give up our fears 
by delusive appearances of amendment, such as subsidence of the 
pulse to the natural standard, or the other remission of symptoms 
already alluded to. 

After what has been said of the prognosis of hydrocephalus, it 
need hardly be added that the result of almost every mode of treat- 
ment is far from satisfactory; and perhaps the best that can be said 
of any is that it is most successful in those cases of meningitis or 
phrenitis which most closely simulate true hydrocephalus. And a 
stronger proof of this need hardly be required than the efficacy often 
ascribed to mercury, which reason as well as experience teaches us 
is more probably injurious than beneficial in true hydrocephalus. 
Wherever, in fact, we have the family and individual history of 
previous liability, with the premonitory signs and characteristic 
mode of invasion of true hydrocephalus, by which we mean the 
central softening with effusion into the ventricles; in these we 



428 ACUTE HYDKOCEPHALUS. 

should expect a priori, and snail generally find, if we make the ex- 
periment, that the action of mercury may be established, so far at 
least as to produce the green stools, which are the surest signs of its 
specific action in children, without any corresponding effect upon 
the symptoms of the disease. Whereas, in more rapid and acute 
cases occurring in robust children whose antecedents are opposed to 
the belief in the existence of strumous disease, we may often find 
mercury a valuable adjunct to other remedies. 

The treatment of hydrocephalus must greatly depend upon the 
constitution of the patient, and the period and intensity of the dis- 
ease. When, as is more commonly the case, we are first called after 
the disease may be said to be established, and the inflammatory 
symptoms are well marked, we must attempt to subdue them by 
evacuants, bearing in mind, at the same time, the delicate constitu- 
tion, and in most cases tender age of the patient. Now it is well 
known that in many cases children bear depletion well ; if the child 
be above the age of three years, blood may be taken from the arm 
to the amount of three ounces or upwards, according to the age of 
the patient; in a severe case, according to Dr. Watson, we may 
apply three or four leeches to a child between three and six months 
old ; and six ounces may be taken from the arm of a child of from 
five to six years old. The same judicious physician observes, how- 
ever, that these quantities are to be regarded merely as approxima- 
tions, the true measure of the quantity of blood to be taken being, in 
all acute diseases, and more particularly in this, the effect which it 
has at the time upon the system. 

Next to depletion, or rather equally with it, the most important 
measure is active purgation; for this purpose we shall certainly 
derive much help from mercury ; two, three, or four grains of calomel, 
according to the age of the patient, and followed after three or four 
hours by an active purgative draught, will generally produce two or 
three full evacuations, provided the latter be retained; but as there 
is often much irritability of the stomach, we must not persist in 
administering it should it be rejected, but have recourse to cathartic 
enemata; — about one scruple of powdered jalap in five or six ounces 
of ordinary cathartic mixture, warmed, will answer well for this pur- 
pose in a child of five years old. When the bowels are acting freely, 
and we wish merely for the revulsive action of the enema, the tur- 
pentine glyster may be preferred. 

In the second stage of the disease, when the inflammatory symp- 
toms are still active, and the head is hot, we have a most powerful 
remedy in the application of cold to the scalp. This may be most 
efficiently done by pouring cold water from a height of two or three 
feet upon the head; but this mode of its application is apt to be too 
depressing, and therefore an evaporating lotion, or what is still better, 
a bladder of pounded ice, is to be preferred. In the use of these, 
however, we must be guided by the temperature of the head, the 
cold application being removed when the cheeks become pale or 
cold. Care must also be taken that the application is constantly cold, as 
when evaporating lotions are allowed to dry there is often a reaction, 



TREATMENT. 429 

and the scalp becomes hotter, and the circulation in the head more 
active than before its application ; the ice-bladders, or the wet cloths, 
must therefore be constantly applied and carefully attended to, unless 
withdrawn for the reasons pointed out above. It is in the confirmed 
hydrocephalus that so much reliance is by many practitioners placed 
upon the action of mercury, and this confidence appears to be enter- 
tained by physicians of high authority; whereas, upon the other 
hand, there is equally high authority for regarding this remedy as 
useless otherwise than as a purgative. It is probable, however, that 
mercury is less useful in proportion as the disease approaches to the 
true hydrocephalus, and that it is in the more rapid cases, with greater 
delirium, occurring in robust children, that we may hope for the 
greatest good from its use. When the bowels are, as is generally 
the case, torpid, the calomel may be used in doses of about two grains 
every four hours for a child of four years old. When there is any 
disposition to irritability of bowels, which there sometimes is, after 
the first difficulty has been overcome, the hydrarg. cum cret. is to be 
preferred. This may be given in doses of three grains ; or the ac- 
companying form may be adopted (F. 81).* The effect of the con- 
tinued exhibition of the mercurial will be the passing of the charac- 
teristic dark-green evacuations, which may be taken as evidence of 
the mercurial action, since young children are rarely salivated, 
though when that happens, there is much danger of sloughing of the 
cheeks. When the heat of the scalp and febrile excitement are sub- 
siding, and the patient if not improving appears to be passing into a 
state of coma, blisters may be applied to the nape of the neck, or 
behind the ears, and in those cases in which the action of mercury is 
thought desirable, the vesicated surface may be dressed with mer- 
curial ointment. It is at this period, too, that diuretics appear to be 
specially indicated. When the pulse is not very feeble, digitalis 
may be given in the form of effusion, in doses of from twenty minims 
to a drachm, according to the age of the child; the combination of 
hydrarg. cum cret. with powered squill may also be used, in the pro- 
portion of about two parts of the former to one of the latter, and this 
is perhaps a good form for the administration of mercury. Colchicum 
has also been highly extolled as almost infallible ; but when we have 
to deal with a disease nearly incurable, we are sure to hear of many 
infallible remedies. 

When there is much irritability and restlessness towards the close 
of the disease, but no stertor, a moderate opiate will often be of great 
service; the best form is Dover's powder, in doses of two or three 
grains. When there is much exhaustion wine may be administered, 
and that freely; its effects being carefully watched ; and, undoubtedly, 
cases apparently desperate have recovered under the use of stimu- 
lants; though it may well be questioned whether such cases were not 
rather those of fever, with head affection, than true hydrocephalus. 

* (81) R. Hydr. Chlorid. gr. ij. 

Hydr. cum. Cret. gr. xij. 
Sacchari purificat. ^ j. Misce. 
Of which gr. iij. to yj. are a dose ; to be repeated every third or fourth hour. 



430 ACUTE HYDROCEPHALUS. 

If the disease in its worst and not least frequent form be thus 
certainly fatal, it is of the first importance to adopt all preventive 
measures ; and as there can be no doubt of the close connection, not 
to say identity, between hydrocephalus and tuberculous disease of 
the encephalon, the principles upon which our prophylaxis is to rest 
must be the same as those laid down for the prevention of other 
tuberculous affections, namely — 1. to counteract the tuberculous 
diathesis by attention to the general health. 2. To obviate the 
tendency of this diathesis to localise itself in the part particularly 
threatened, namely, the encephalon. 

For fulfilling the first indication we must apply, according to the 
age and circumstances of the patient, the principles already laid down. 
There can be no doubt that the great amount of the strumous disease 
amongst children in our large towns, arises no less from errors as to 
ventilation, light, food, clothing, and cleanliness, than from any here- 
ditary taint in the parents. Although some have been found to deny 
that strumous disease can be generated de novo in a child born of 
healthy parents, yet none can reasonably entertain a doubt, that 
though the parents may have no hereditary taint, yet if their health 
be deteriorated by the above causes, their children, who are also in 
most cases of necessity exposed to the same, will become in many 
instances the victims of scrofula, and therefore not only should 
rational prophylactic measures be enjoined, upon every opportunity, 
as regards the children themselves, but parents should be made 
aware that their own intemperance, improvidence, or neglect, may 
be visited upon their children in early death or ruined health. And 
this applies with equal force to all classes of society ; the profligacy 
and intemperance, or the excitement and bad atmosphere of the count- 
ing-house or the gaming-table, on the part of the father, acting upon 
the health of the offspring no less than the confined workshop or the 
excesses of the gin-shop; and this applies to the self-indulgence or 
drudgery of dissipation on that of the mother, no less than to excessive 
labour, anxiety, privation, or spirit-drinking. 

The careful. ventilation of sleeping apartments, as well as cleanli- 
ness, require care in all classes, as do also the most free admission 
possible of air, and solar light; the importance of this latter, as affect- 
ing the health of young children, being generally not sufficiently 
appreciated. The clothing of all children in this climate requires 
care, especially of those who, either from any family tendency or 
from locality, may be prone to strumous disease; it should be uni- 
form over the trunk especially, not heating, but composed of material 
of little conducting power of heat. As regards diet, where the mother 
is healthy, and has a good supply of milk, the child should be kept 
at the breast for a year ; and when the supply begins to fall off before 
that time, the child should be fed with arrow-root, or tops and bot- 
toms softened in milk, so as to be taken through a bottle; the feeding 
children with a boat or even a spoon before they have teeth being 
a practice that cannot be too strongly reprobated. 

Whilst great care is to be taken to avoid the effects of cold or 



TREATMENT. 431 

damp, equal caution must be used to prevent the child becoming too 
susceptible of its influence, and for the purpose of hardening him 
against it there is no means more effectual than the use of the bath. 
Most children can bear a bath of the temperature of the room; but 
should the circulation be so feeble that there is no reaction after its 
use, the temperature of the water should be raised five or ten degrees 
above it. 

It is, however, with preventing the disease from localising itself in 
the encephalon that we are now mainly concerned; and here we 
must bear in mind the principle upon which we are to act, namely, 
the obviating all undue excitement of the organ threatened. To this 
end precautions should be taken from the first, and amongst the 
earliest of these should be the keeping of the head cool; the child 
should be early disencumbered of its cap, both by night and day; 
here we must, in some degree, qualify what has been said respecting 
light, since the excitement of a too-powerful light is to be carefully 
shunned whenever the child evinces the least susceptibility to cere- 
bral irritation. The same applies to loud noises, which are at all 
times painful; and from the irritation and excitement which they 
frequently induce, may bring on spasmodic affections ; and, therefore, 
there is good reason to believe that they may promote that determi- 
nation to the head which favours development of tubercle in the 
encephalon. When any tendency to tuberculosis is to be appre- 
hended, either from the constitution of the child or from his ante- 
cedents, we have reason to fear its development in the brain ; and, 
therefore, we must guard against whatever strongly stimulates the 
sensorial nerves, excites the spirits, or promotes the too rapid or early 
development of the intellectual faculties. On these grounds we 
cannot too peremptorily forbid the tossing, and jumping, and halloo- 
ing to children in arms, often practised by heedless nurses or friends ; 
neither can we too earnestly restrain the vanity or injudicious zeal 
of parents in urging children, with such- a tendency (and be it remem- 
bered that such children have generally a precocity of intellect that 
almost holds out a temptation to doing so), to the exercise of their 
intellectual faculties, and the attainment of acquirements beyond 
their age, which, if it does not hasten on a fatal malady, is often pro- 
ductive of a result opposite to that expected: the over-stimulated 
intellect, like the overgrown body, evincing in the man a feebleness, 
and want of power of sustained exertion, which the inexperienced 
would hardly have anticipated from the early intelligence and 
unusual aptitude for learning of the child. At the same time that 
these negative precautions are enjoined we must not overlook the 
more direct ones of combatting the earliest manifestations of cerebral 
disorders. The state of the evacuations should be carefully watched, 
and when the bowels are sluggish, a moderate aperient should be, 
from time to time, administered. For this purpose a good form is 
the combination of rhubarb and hydrarg. cum cret. or calomel with 
jalap, which may be helped with from one to two drachms of castor- 
oil on the following morning. There is, perhaps, some ground for 



432 ACUTE HYDROCEPHALUS. 

difference. of opinion as to the "use of iron in such cases, and expe- 
rience teaches us that, in general, it is too liable either to stimulate 
the circulation, or to induce congestion, to be a safe remedy; per- 
haps where there is pallor, the syrup of the iodide, in small doses, may 
be used; but iodide of potassium, combined with a vegetable tonic, 
would, in the majority of instances, be a more effectual as well as a 
safer medicine. The syrup of the iodide of zinc, as prepared by 
Mr. Davenport, will also be found a most useful medicine, combining 
at once the alterative properties of the iodine with the tonic but 
unstimulatino- ones of the zinc. 

The hydrocephalus, of which we have just been speaking, is upon 
the whole to be regarded as the effect of inflammatory action, though 
of a low character, and one belonging to a peculiar constitutional 
diathesis; but there is a form of hydrocephalus which is of a non- 
inflammatory character, and in its most exquisite form to be viewed 
in the light of a simple dropsy of the brain, arising, in many cases, 
from obstructed circulation by occlusion of, or pressure upon, the 
sinuses, or from atrophy of the brain, through disease of the arteries. 
In the majority of instances, however, chronic hydrocephalus is the 
result of antecedent acute disease of the arachnoid, of that part more 
especially which lines the ventricles. In the greater proportion of 
cases, thirty-six out of fifty according to Dr. West, the disease had 
its orisrin before birth. 

The diagnosis of chronic hydrocephalus is self-evident. 

The prognosis is in the main decidedly unfavourable, though there 
have been many probably of a somewhat sub-acute character, in 
which there have been undoubted effusion, and that, too, of a con- 
siderable quantity, which has been much reduced by remedies, and 
probably in the end entirely removed. When the sutures are open, 
the case is more favourable, both because the brain suffers less from 
the pressure, and also, because there is greater opportunity for the 
adaptation of the capacity of the calvarium to the altered amount of 
its contents. 

As this form of the disease is, like the acute, if not essentially and 
directly of a tuberculous character, at least most closely connected 
with the tuberculous diathesis, we must direct our dietetic and gene- 
ral treatment to obviating the constitutional tendency; at the same 
time we may also have recourse to occasional alterative doses of 
mercury (F. 82).* Care should be taken to insure its moderate ape- 
rient action, as it is very doubtful if there is any benefit to be derived 
from the direct action of the mercury upon the system. The remedy 
from which, however, most good may be expected, is the iodide of 
potassium. This will best be used in combination with an alkali, to 
prevent the iodine being rendered irritating by the salt meeting with 
any free acid in the intestines ; about a drachm of the annexed mix- 

* (82) R. Hydrarg. Chlor. gr. ij. 

Sodse Carb. exsic gr. viij. 
Pulv. Cretae co. 9 J- M. 
From gr. vij. to xvi. to be taken every other or every third night. 



CEKEBKO-SPINAL MENINGITIS. 433 

tare may be given to a child of a year did (F. 83).* The absorption 
may, perhaps, be helped, from time to time, by the addition of a 
small quantity of infusion of digitalis, of which about fifteen minims 
may be given to a child of a year old ; but its use should not be 
continued for more than four or five days together. Blisters may 
also be applied behind the ears in children of a year old and upwards. 
A good rule for their use is to allow the plaster to remain on for 
one hour, and then remove it ; and if there be no vesication at the 
end of an hour after its removal the same proceeding may be 
repeated. 

The general treatment and hygienic measures for the prevention 
of chronic hydrocephalus must be the same as those employed against 
the acute form of the disease. 



[CEKEBKO-SPINAL MENINGITIS. 

Sporadic cases of inflammation affecting the meninges of the brain 
and medulla spinalis are occasionally met with, but it is from its 
frequent occurence as an epidemic in different portions of Europe 
and the United States, that cerebro-spinal meningitis has, of late 
years, attracted attention. 

The disease in many instances occurs suddenly, without any pre- 
monitory symptoms. In general, however, it is preceded by more 
or less of pain of the head, especially of the forehead, temples, or 
occiput. The pain is usually constant, but occasionally remittent, 
or even intermittent. Pain is, also, sometimes experienced in the 
back of the neck and along the course of the spine, with a sense of 
soreness in the limbs and joints. In a few cases the attack is pre- 
ceded by a sense of giddiness, with or without dimness of vision. 

In some instances the attack commences with a feeling of chilli- 
ness, succeeded by a slight increase in the heat of the surface, and 
pain, extending from between the shoulders to the occiput, with stiff- 
ness, to a greater or less extent, of the posterior cervical muscles. 
Or, the patient may be attacked by chilliness, pallor of countenance, 
coldness of the extremities, low moaning, or muttering delirium, 
quickly succeeded by restlessness, flushing of the face, a frequent 
pulse, a wild expression of the eyes, and a hot and dry skin. In 
other cases, the disease may be ushered in by a sense of lassitude 
and uneasiness, considerable prostration, and a dull heavy pain of the 
head, with more or less vertigo, especially when an attempt is made 
to assume the erect position ; the eyes are languid and half-closed, 
the speech laborious and indistinct ; occasionally the patient is sud- 

* (83) R. Pot. Iodidi, gr. iv. 
Sp. iEth. Nit. 3 j. 
Liq. Potassas, n^ xxiv. 
Tinct. Hyoscy. 5 j. 
Syrupi Aurant. 3 ii. 

Aq. Purse, quant, suf. ; to make a two ounce mixture, of which 
from 3 j. to iv. are to be taken three times a-day. 

28 



434 CEREBRO-SPINAL MENINGITIS. 

denly attacked with deep comfe, or with more or less stupor, attended 
by a sense of extreme debility, giddiness, dimness of sight, or double 
vision. Or, the attack may commence with severe pain of the 
abdomen, succeeded immediately by nausea, and perhaps vomiting. 
In violent attacks of this character, the extremities become, at the 
same time, cold and of a bluish colour, and the pulse is reduced to a 
mere thread. After a few hours, reaction, more or less perfect, 
ensues. 

Whatever may be the character of the initiatory symptoms, they 
are replaced, after a period of variable duration, by a state of violent 
agitation, or by a state of stupor more or less decided, with a slow 
occasionally full pulse, and dilated and immoveable pupils. When 
in this condition, on touching any portion of the patient's body will 
sometimes cause him to emit a short plaintive cry ; at others, the 
patient utters, from time to time, acute cries, and carries his hand 
frequently to his head. When spoken to, he will, in general, exhibit 
a degree of consciousness, by a motion of the head, by an attempt to 
articulate, or by opening his eyes for a moment. 

Pain, more or less intense, of the head and along the spine, is pre- 
sent in the early stage of nearly all cases. Pressure applied to the 
cervical portion of the spine will often produce pain of the head 
darting to the forehead, eyes, and temples, as well as pain at the top 
• of the sternum ; while pressure on the dorsal vertebras will cause 
pain at the middle of the sternum, or about the umbilicus, according 
as it is made higher or lower. The pain is frequently severe, and 
continues for some time after the pressure is removed. 

From an early period of the attack, delirium is very commonly 
present, often attended with contraction of the pupils, or, occasion- 
ally, with dilatation of one pupil and contraction of the other ; some- 
times with ptosis of the eyelids, and ecchymosis under the eyes. 
Ordinarily, the delirium lasts but a short period, but quickly returns. 
The mind of the patient is in most cases desponding and apprehen- 
sive. 

More or less intolerance of light and sound is present in the majo- 
rity of cases : in some it is to such an extent that the slightest ray of 
light or the least unusual sound is apt to excite convulsive move- 
ments. In the first period of the attack, imperfect vision has been 
occasionally noticed; the patient seeing objects double, or only 
one-half of them, Or they appear to him as if enveloped in a mist. 

The conjunctivas are often injected, and the eyes of a glittering 
and watery aspect. 

Insensibility of the eyes to light, and complete blindness of one 
or both eyes have been noticed as present in many cases. 

Violent inflammation of one or other eye has been described as of 
frequent occurrence in some epidemics. 

Partial or complete deafness is present in some cases ; in others a 
constant ringing in the ears is complained of from an early period of 
the attack. 

There is often present an exalted sensibility of the entire surface 
of the body, the patient wincing upon the slightest touch, even of 



SYMPTOMS. 435 

the bed-clothing, and refusing to change his position, from the pain 
consequent upon every attempt at motion. 

In very violent cases, petechias occur upon the extremities and 
over the eyelids, within a few hours after the attack. An exanthe- 
matous eruption, also, occasionally makes its appearance. 

The respiration is sometimes irregular and laboured — a difficulty 
would appear to be experienced in some cases in expanding the 
lungs — with respiration chiefly through the nostrils. Stertorous 
respiration is not a frequent symptom. 

There is often continued irritability of the stomach, with insatia- 
ble thirst, and tenderness of the epigastrium upon pressure. 

Constipation and suspended secretions are common symptoms of 
the disease. 

The tongue is usually more or less coated with a pale ash, white 
or yellowish fur. In the more grave and malignant forms of the 
disease it has been observed to be broad and flabby — sometimes so 
enlarged as to impede articulation, and becoming indented around its 
edges by pressing upon the teeth. An increased flow of saliva is 
commonly present. 

During the period of excitement the pulse is usually full and fre- 
quent — from 120 to 140 in a minute — often, however, it is very 
slow — sinking, sometimes, to 48 or 50 in the minute. The pulse, 
however, has been observed to vary in the number of its beats at 
different periods of the day. 

The most striking characteristic of cerebro-spinal meningitis is 
presented by the condition of the muscular system. The muscles of 
the neck in particular become rigidly contracted, drawing back the 
head upon the vertebral column, and firmly fixing it in that position, 
so that the patient is unable to move it forwards ; neither can this be 
done by the attendants with the employment of any justifiable force. 
The countenance at the same time assumes very much the tetaniG 
expression. In some cases, the contraction is confined to the sterno- 
mastoid muscle of one or both sides ; in others, again, it is the 
extensors that are principally affected, the head being retained 
permanently in its natural erect position. 

The rigidity is very commonly observed in the muscles of the 
extremities also. The patient loses the power of moving his limbs 
and of assuming the erect posture. In some instances there is a 
quivering motion of the muscles of the face, with tremors of the 
hands, and embarrassment in the movements of the extremities, or 
spasmodic twitchings in the flexors of the limbs, with a disposition 
to a constant movement of the legs from side to side, alternately. In 
some epidemics, rigidity of all the spinal muscles was a common 
symptom — occasionally, the whole spine, from the occiput to the 
sacrum, being bent forcibly backwards, like a well-strung bow, so as 
to prevent the patient from lying flat upon his back. Contraction of 
the recti muscles of the abdomen is often present. 

In many cases there is a difficulty of prehension, it being with 
great difficulty that the patient can take and drink water from any 
vessel without assistance. In some cases involuntary twitchings of 



436 CEREBKO-SPINAL MENINGITIS. 

the muscles are produced whenever the patient attempts to move or 
seize any thing, as if he were under the influence of strychnia. In 
others, violent convulsions are induced the moment the inferior 
extremities are raised up, or merely touched. 

There is great irregularity as to the period when the tetanic symp- 
toms occur. They may set in as early as the first day of the attack, 
or not until after the lapse of several days. 

Cerebro-spinal meningitis, although it is, in general, marked by 
pain of the head, more or less intense, rachialgia, heat of the scalp, 
congestion of the conjunctivae, some degree of intolerance of light and 
noise, exalted sensibility of the cutaneous surface generally, tendency 
to coma, and a tetanic affection of the muscles of the neck and per- 
haps extremities, may, nevertheless, in many instances, present no 
symptoms of so decided a character as to lead us to suspect the exist- 
ence of serious disease of the brain and spinal marrow, until the 
laboured pulse, the dilated pupil, the profound coma, or the severe 
spasmodic or convulsive attacks indicate but too plainly the near 
approach of death. 

In other cases again, and these by no means of rare occurrence, 
symptoms of a most formidable character may present themselves at 
the very onset of the disease. Thus, the patient may be attacked at 
once with violent paroxysms of general convulsions, requiring manual 
restraint to protect him from injury ; or he may suddenly, without 
any striking premonitory symptoms, sink into a state of coma almost 
apoplectic in its character, or, into a half unconscious condition, with 
constant moaning or plaintive cries, and grinding of the teeth. 

Intermissions of a periodic character are not uncommon in this 
disease. So complete, in some instances, will be the cessation of all 
the prominent symptoms as to lead to the hope of the speedy recovery 
of the patient, the fallacy of which is shown by the return of the symp- 
toms in perhaps a more aggravated form, on the following day. 

When death is not early induced by the violence of the attack, the 
patient sinks, more or less rapidly, into a state of profound coma, his 
pulse becomes slow and labouring, his power of speech and degluti- 
tion entirely fail, his tongue becomes dry, and, together with the lips 
encrusted with dark sordes ; his stools are passed involuntarily, while 
his bladder becomes distended with urine, or allows it constantly to 
dribble away : death finally closes the scene, often preceded by para- 
lysis of one side of the body, or of one or other extremity. 

The duration of the disease is very variable. Death may occur 
within a few hours from the commencement of the attack. The 
generality of cases terminate about the fourth day ; some, however, 
are prolonged over fourteen, twenty, or even fifty days. Conva- 
lescency is usually slow and lingering. Even after an apparently 
perfect recovery, secondary diseases are apt to occur, and sooner or 
later destroy the patient. 

The diagnosis in cerebro-spinal meningitis is somewhat obscure. 
There is no symptom or series of symptoms which can be considered 
as strictly pathognomonic. The disease is in general characterised 
by acute and fixed pain of the head, rachialgia ; aversion from light ; 



PROGNOSIS — ANATOMICAL LESIONS. 437 

injection of the conjunctivae; increased sensibility of the surface; 
acute cries; low, muttering delirium or coma; pain and stiffness of 
the posterior cervical muscles, with permanent retraction of the head; 
often rigidity of the large extensors of the spine; spasmodic tremors 
or twitchings of the muscles, particularly of the face; tetanic convul- 
sions of the limbs. When a disease, marked by several or all of the 
above symptoms, occurs as an epidemic, we may pretty confidently 
pronounce it to be cerebro-spinal meningitis. 

The prognosis is for the most part unfavourable — sporadic cases, it 
is true, frequently do well under an appropriate treatment, but in its 
epidemic form, it has terminated fatally in the great majority of cases. 
When the attack commences with great prostration, coma, and general 
symptoms of collapse, death often ensues in a few hours without the 
occurrence of reaction. Few cases recover after severe tetanic symp- 
toms make their appearance. Irregularity of respiration, difficulty 
of swallowing, great enlargement of the tongue, extensive petechias, 
violent general convulsions, and deep, persistent coma are all unfa- 
vourable symptoms. 

The anatomical lesions detected in the bodies of those who have 
fallen victims to the disease are chiefly confined to the meninges of 
the brain and spinal marrow. The pia mater is deeply injected with, 
blood, and the large vessels and sinuses of the brain remarkably 
turgid. The arachnoid is slightly opaque at different points, with its 
free surface generally dry and clammy. More or less serosity, either 
lactescent or turbid, yellowish, and often semi-gelatinous is found in 
many cases effused beneath, the arachnoid. In others, drops, varying 
in size, of a yellowish colour and purulent appearance, are dissem- 
inated along the course of the vessels. More generally, patches, or 
bands of a consistent substance, of a yellowish, or greenish colour, 
resembling concrete pus, are met with on the surface of the pia 
mater, at the upper and lateral portions of the hemispheres, but 
especially at the base of the brain, in the space corresponding to the 
circle of Willis; many of the cerebral nerves being, at their origin, 
imbeded in it. It passes over the infractuosities, rarely penetrating 
into them. In the spinal canal, this puriform matter extends along the 
anterior or posterior face of the medulla, and, occasionally, competely 
envelopes it, extending often to the extremity of the cauda equina ; 
investing each of the spinal nerves at its source. In some cases true 
purulent collections are present. These morbid deposits are confined 
as in the cranium to the sub-arachnoid space. 

In a few cases inflammatory effusion is met with in the ventricles 
of the brain, with increased vascularity of the choroid plexus; more 
rarely the substance of the brain and spinal marrow is found softened 
to a greater or less extent. Sometimes on dividing the brain, besides 
the red points commonly present in cases of congestion and inflam- 
mation, there is observed an immense number of red vessels, contain- 
ing sometimes fluid, and at others, coagulated blood. Similar vessels 
are seen, also, upon removing the membranes, ramifying over the 
base of the brain, and also over the floor and walls of the ventricles. 

There is reason to believe that when the substance of the brain and 



438 CERERRO-SPINAL MENINGITIS. 

spinal marrow is found affected it has become so secondarily, from 
the extension to it of disease primarily located in the meningeal 
envelopes. 

Whenever purulent effusion is detected on the spinal medulla, it 
is also met with on the brain; occasionally, however, it is confined 
entirely to the latter, from which circumstance it has been inferred 
that the inflammation in cerebro- spinal meningitis commences always 
in the encephalon, and from thence extends to the spinal meninges. 

The rapidity with which suppuration may occur in this disease is 
surprising. Cases are recorded in which pus was met with, although 
death had occurred in fifteen, thirty-six, and forty-eight hours from 
the onset of the disease. 

Slight redness of different portions of the gastro-intestinal mucous 
membrane is occasionally met with, in the form of patches, arborisa- 
tions, or dots. In some instances a diseased condition of the follicles, 
in others, thickening, or softening, to a greater or less extent, of 
portions of the mucous membrane of the stomach and ileum are pre- 
sent; while, in other cases, again, enlargement, and even ulceration 
of the agminated and solitary glands of the lower portion of the 
ileum, with enlargement, reddening, or softening of the mesenteric 
glands, have been observed. These lesions of the digestive organs 
have almost invariably occurred in patients who survived the first 
few days of the attack, from this fact, and their infrequency, they can 
be viewed only as the result of an accidental or secondary affection. 

In the post mortem examinations made at Versailles, in 1839, the 
left cavities of the heart were found to be almost entirely empty, 
while those of the right side were filled with large fibrinous coagula, 
of a yellow colour and some consistence. The same thing was 
observed by the physicians in other parts of France, especially in 
cases in which the blood drawn during the life time of the patient 
was buffy and contained but little serosity. Dr. Ames, of Alabama, 
found the blood drawn from the arm, and by cups, to form large, 
loose coagula, in which all the red globules were rarely included. 
The serum separated slowly, and in small quantity. The colour 
was in general bright — in a few cases approaching to that of arterial 
blood. Of thirty cases, it was buffed in only four. It presented an 
excess of fibrine. In four analyses of the blood, procured in two 
cases at the first venesection, in one at the second, and in another at 
the third, M. Tourdes states, that the principal alteration detected 
was an increase of the red globules and of the fibrine, but especially 
of the former. 

As already remarked, it is chiefly from the occurrence of cerebro- 
spinal meningitis as an epidemic that the disease has of late years 
attracted the attention of physicians. These epidemic visitations are 
occasionally confined within very narrow limits, while, at others, as 
was the case in France, between the years 1837 and 1842, they spread 
successively over extensive regions. Their occurrence would appear 
to be altogether independent of any morbific agency referable to 
peculiarities of climate, season, or locality. Age, and to a certain 
extent sex, would appear to rank as predisposing causes of the dis- 



TREATMENT. 439 

ease, whatever may be the nature of the epidemic agent by which it 
is produced. Its subjects, wherever it has so occurred, have been 
young persons of the male sex. In Ireland, boys under twelve 
years of age were those almost exclusively attacked. In Gibraltar, 
in the great majority of cases, it occurred in subjects — chiefly males 
— between two and fifteen years of age. In Tennessee, its principal 
victims were children between the ages of six and fifteen years. In 
Missouri, between ten and fifteen years. In San Augustine, Texas, 
the patients were generally under fifteen years ; in but two or three 
instances did the disease attack those over eighteen years of age, and 
not in a single instance a female. In Alabama, however, the majority 
of those attacked — over fifty per cent. — were beyond twenty years of 
age. Ffty-four per cent, were males. In Texas there was not an 
instance of the disease occurring among the negroes, who were pro- 
bably more exposed to morbific agencies than the whites. 

In regard to the treatment of cerebro-spinal meningitis, owing to 
the rapid march of the disease in the larger number of cases, there is 
little time left for the application of those remedies which its charac- 
ter, as indicated by the symptoms present during the life of the 
patient, and the lesions discovered upon dissection after death, would 
point out as the most appropriate. At the height of the epidemic, 
in those cases especially in which the attack commences with symp- 
toms of extreme violence, as well as in those where symptoms indi- 
cative of extreme collapse are present at the very onset of the dis- 
ease, the most judicious and best directed plan of treatment will very 
generally fail to arrest a fatal termination. 

At the commencement of the attack, when symptoms of prostra- 
tion and of deep stupor are absent, as well as during the early period 
of the stage of excitement, there can be no doubt of the propriety and 
efficacy of direct depletion. 

In all cases, then, of the character just described, free bleeding 
from the arm should be resorted to without delay. The amount of 
blood to be drawn is to be measured by the age and condition of the 
patient, and the effect produced. If a weak pulse rise, or a strong 
one retain its character during the flow of blood, this may be allowed 
to continue; but when the pulse becomes weak, a moisture breaks 
out upon the surface, and the face become pallid, indicating approach- 
ing syncope, the flow of blood should be at once arrested, even 
though we may be required to re-open the vein a few hours subse- 
quently, should the pulse again rise, and the face become once more 
flushed. We are not, however, to proportion our bleeding to the 
degree of restlessness and delirium with which the patient may be 
affected. These violent states of nervous erethism quickly exhaust 
the powers of life, and were a too copious venesection to be resorted 
to, a sudden and speedily fatal collapse would be liable to ensue. 

Subsequently to general bleeding, cups should be applied to the 
back of the neck, and along the spine, and leeches to the temples, to 
the neck, and behind the ears, and repeated at short intervals, so long 
as any indication for direct depletion remains. 

After the first bleeding an active mercurial cathartic should be 



4:40 CEREBKO-SPINAL MENINGITIS. 

administered, and cold applied to the head by means of a bladder 
half filled with powdered ice, or cloths wet with iced water, or iced 
water and vinegar, the hair being first removed. At the same time 
the feet and legs should be immersed in hot water, followed by sina- 
pisms to the feet and ankles. 

In conjunction with direct depletion by the lancet, active purgation 
will unquestionably be found an efficient remedy, by producing a 
revulsion from the diseased organs. There are but few cases in 
which the presence of gastro-enteric inflammation will forbid the 
employment of purgatives. 

Tartar emetic, in divided doses, combined with the saline diapho- 
retics, will no doubt prove beneficial in the early period of the stage 
of excitement. In the epidemic which occurred at Yicksburg, Miss., 
Dr. Hicks gave it in combination with camphor, and, as he states, 
with the best effects* 

After blood-letting has been carried as far as it is thought prudent, 
under the circumstances of the case, especially if the patient falls into 
a state of coma, with feeble pulse and deficient reaction, blisters along 
the whole course of the spine will often be found of advantage. 
According to Dr. Ames, blisters to the upper portion of the spine 
very generally had the effect of removing or greatly relieving the 
cephalalgia, even when bleeding had failed to do so. In the malig- 
nant forms of the disease, the relief afforded by them was very great. 
Blisters to the scalp have been advised ; we doubt, however, the pro- 
priety of their application to this part. 

In those cases where the attack commences with symptoms of 
collapse, or where such symptoms ensue after a transient and imper- 
fect reaction, the most powerful excitants, mustard, ammonia, or tur- 
pentine, aided by heat and friction, should, without delay, be applied 
externally along the spine and to the extremities, and perse veringly 
employed, at short intervals, until the torpid sensibility is aroused. 
It is probable that, in these cases, the actual cautery, as employed by 
M. Rollet, will be found of advantage. He passes the iron, at a 
white heat, six, eight, or more times, at as many different points, 
along each side of the spinal processes. M. Kollet states that, in the 
worst cases, the first application of the actual cautery does not elicit 
from the patient any indication of sensibility, it is only at the third, 
fourth, or even fifth application that a slight muscular movement 
proves that pain is experienced. Some patients utter cries during 
the last applications, but immediately relapse again into a comatose 
condition. 

Should we succeed in establishing reaction, the patient must be 
carefully watched, and if it transcend the proper grade, resort should 
be immediately had to general and local blood-letting, to an extent 
proportioned to the violence of the symptoms, and the age and 
strength of the patient, at the same time, cold applications should be 

* R. Antimon. Tart. gr. ij. 
Pulv. Camphorse, g ij. 
Mucil. g. Acacise, ^ vj. M. 
Dose, a tablespoonful every two hours. 



TREATMENT. 441 

made to the head, and the other means of keeping down excessive 
reaction employed. 

By several of the American writers on the disease, the early and 
free exhibition of mercury, both by the skin and month, with the 
view of producing promptly its specific action, is favourably spoken 
of. Dr. Ames, of Alabama, considers it a more efficient remedy 
than blood-letting, as weil in the promptness as in the permanence 
of its beneficial effects* 

The French physicians condemn mercurial frictions — more, how- 
ever, we suspect, from theoretical views, than from any actual expe- 
rience of their bad effects. 

It is proper to remark that, in many cases, mercury, even when its 
specific effects have been induced early in the attack, has failed to 
exert any perceptible influence in retarding the fatal march of the 
disease. The same remark, however, may be made in reference to 
every other remedy that has been resorted to in this disease. Sub- 
sequent to venesection and the employment of the other antiphlo- 
gistic remedies, the administration of opium has been recommended 
by several of the French physicians. Forget commenced its use 
between the fifth and seventh clays of the disease, in the form of a 
syrup containing half a grain of opium as a dose for an adult. This 
he found to relieve the pain of the head, and to calm the delirium 
and muscular spasms. M. Chaufard states that the early employment 
of the most energetic antiphlogistic means failed in his hands to cure 
the disease, but he found it to be promptly arrested by opium given 
in large doses, — in many cases it was advantageously combined with 
quinia. Before this plan was adopted, we are told, only one case 
was cured out of thirty, but afterwards the disease was even less 
fatal than in its sporadic form. M. Tourdes admits, with M. Chau- 
fard, the inefficacy of the usual antiphlogistic remedies, but cannot 
agree with all the latter has said in praise of the curative effects of 
opium. Dr. Ames, of Alabama, does not consider the latter as gene- 
rally safe in the more violent inflammatory cases, nor of any use in 
the congestive malignant cases. In the other forms of the disease, 
he speaks of it as a safe and very valuable remedy. At St. Augus- 
tine, Texas, we are informed by Dr. Roberts, that opium and mor- 
phia were tried in a few cases, but without any good result, they 
appeared rather to increase the stupor, without relieving the pain 
and restlessness. 

To produce a sedative effect, some of the French practitioners 
employed, subsequent to antiphlogistics and revulsives, the water of 
the cherry laurel and that of valerian combined with mucilage. M. 
Maihle recommends in preference, the distilled water of bitter 
almonds, as furnishing more definite proportions of hydrocyanic 
acid. 

Quinia is recommended as a most efficacious remedy in cerebro- 
spinal meningitis by certain of the French army physicians: by the 
majority, however, it is denounced as positively injurious. It was 
frequently employed by Dr. Ames in the graver forms of the disease, 
and sometimes with partial success. When the disease was attended 



442 CEKEBRO-SPINAL MENINGITIS. 

by fever of a regular remittent form, he found it occasionally to 
arrest the paroxysms.- In other forms of the disease, he found it, if 
not absolutely injurious, to afford not much encouragement for its 
repetition. 

Dr. Ames speaks highly of the effects of potass in this disease. 
It was given to children in doses of from three to five grains, every 
two hours. JSTo case proved fatal in his practice, nor, so far as he 
could learn, in which the potass was freely and continuously em- 
ployed. In many cases, unattended with febrile symptoms, properly 
so called, under the use of the remedy, the cephalalgia was speedily 
and permanently relieved, and in others, its administration was 
followed by a prompt reduction of arterial excitement, delirium, and 
the intense pain of the head. 

Etherial inspiration, it is said, was practised, with the best effects, 
by M. Basseron, physician-in-chief to the Military Hospital of Mus- 
tapha, in Algeria. 

During the period of excitement, cooling drinks should be allowed, 
and a strictly antiphlogistic diet enjoined. Absolute rest and quiet, 
with the seclusion of light, as far as it is consistent with due ventila- 
tion, are all important. In the comatose cases, and during the stage 
of collapse, care should be taken to prevent an accumulation of urine 
in the bladder. 

Convalescence from epidemic cerebro-spinal meningitis is usually 
protracted, and relapses are liable to occur from slight errors in diet 
and regimen, hence the greatest watchfulness is to be observed until 
the general health and strength of the patient are fully re-established. 

Dr. Hicks found the annexed prescription* to act as a most admi- 
rable tonic, after the violence of the disease had been subdued, for 
relieving the inertia of the nervous system that remained in every 
instance in which recovery took place. 

* R. Iod. Ferri, ^ j, 

Iod. Potass. ^ ij. 
Iodini, gr. viij. 
Syr. Sarsapar. % iv. M, 
Given in closes of a teaspoonful every four hours, in a little water. 



DELIRIUM TREMENS AND MANIA. 443 



XXV. 
DELIBIUM TKEMENS AND MANIA. 

Delirium tremens, or the mania a potu of the older authors, is a 
disease which we recognise, and can define only by its symptoms, 
since it belongs to that class of nervine affections, in which defect or 
derangement of the nervous power arises independently of any 
structural change cognisable to our senses. 

The whole of the symptoms in this affection, are essentially those 
of exhaustion, with that state of the nervine functions so commonly 
associated with it, and which is recognised, amongst medical men, as 
that of excessive irritability. This disease attacks exclusively those 
who have been subject to a long series of excessive nervine stimula- 
tion, accompanied by circumstances tending to derange the circula- 
tory and digestive organs. All these conditions are combined in 
repeated and continued alcoholic intoxication, and therefore it has 
been regarded as especially a drunkard's disease, and hence the 
synonyme mania a potu: this, however, though true of by far the 
greater number of iu stances, is not so universally. 

The disease generally commences, or is preceded, by more or less 
of febrile excitement, during which there is often a sense of horror 
of some impending calamity, or the patient entertains a suspicion of 
some plot laid against him ; there is a continued movement of the 
eyes, as if in apprehension of some approaching danger ; hurriedness 
and excitability of manner ; a degree of tremulousness in the limbs, 
and the same is observed of the tongue when the patient is asked to 
protrude it. This excitement and tremulousness continue until to 
the dread of approaching danger are added hallucinations, and the 
patient believes that he sees persons or other objects approaching to 
do him mischief. In this state of excitement he will, unless carefully 
watched, elude the restraint of his friends, and walk or run hurriedly 
for long distances, as if endeavouring to escape pursuit. These hal- 
lucinations are accompanied by delirium, the patient generally assert- 
ing that he is in some other place, commonly, to all appearance, under 
the idea that he has been kidnapped or removed by stealth or force ; 
and whilst suspicious of all about him, he is more especially so of his 
nearest relatives, and those in whom he is most used to trust ; his 
talking is incoherent, generally, however, in accordance with his 
hallucinations, or about some disappointment or loss in business, or 
some subject which has caused him peculiar anxiety of mind. This 
last form of delirium is more particularly observable in those in whom 
the disease has been induced by some circumstances other than in- 
toxication. Sometimes, however, there is a degree of hilarity about 
the patient, and he will sing and be jocose at intervals. It is one of 
the peculiarities of this form of delirium, that a word will often bring 
him to a state of reason, though only for a very short time, after 



444 DELIKIUM TREMENS. 

which lie immediately recurs to his former delusions. With all this 
excitement, the pulse, though rapid, is very compressible, and the 
tongue is creamy and moist, the skin perspires freely, the urine is 
abundant, the bowels, though torpid, not obstinately constipated, and 
the pupils rather dilated, though obedient to the stimulus of light. 

If the disease be not checked by the appropriate treatment, the 
patient passes into a state of coma, or what is equally frequent, sub- 
sides rapidly from excitement to exhaustion, and sinks from gradual 
syncope. Another danger to be apprehended is the patient's de- 
stroying himself, either accidentally in his anxiety to escape from his 
imaginary danger, or by direct injury inflicted upon himself. 

The most common cause of delirium tremens is, as has been stated, 
intemperance, the disease generally commencing after a continuance 
of excessive drinking, wound up, perhaps, by an extraordinary de- 
bauch. Sometimes, too, the approach of the disease seems to cause 
an increased desire for stimulating drinks, this giving rise to some 
very great excess, the depression consequent upon which is the 
beginning of the attack. Sometimes it happens that, owing to a 
threatened attack of apoplexy, or some inflammatory affection, real 
or presumed, the patient is bled, or blood is lost by some accident 
incurred in a drunken fit; or it may be that the state of the liver, 
induced by alcohol, gives rise to an attack of hasmatemesis, and the 
loss of blood appears to be the immediate cause of the invasion of 
delirium tremens. It may be, too, that the sudden withdrawal of his 
accustomed stimulants brings it on when such stimulants have been 
forbidden, owing to the patient being under treatment for disease or 
accident. Sometimes a drunkard in a fit of remorse determines to 
abstain entirely, and this too may induce the disease. Intemperance 
in the use of alcoholic drinks is not, however, the alone cause of 
delirium tremens, indeed it may be questioned whether it is ever, in 
the strictest sense of the word, a cause at all, since its effect is merelv 
to induce a state of susceptibility to those influences which are the 
real cause, and to which intemperate habits render him peculiarly 
exposed ; and many cases have occurred which seem to show that 
this susceptibility may be induced by long-continued excitement of 
the nervous system in other ways. The excessive attention to busi- 
ness, where that business is of an exciting kind, has, when the excite- 
ment has ceased or been abruptly brought to a close by some heavy 
reverse, been known to be followed by the symptoms of delirium 
tremens. Another instance is afforded bv the case of a young me- 
dical practitioner, of strictly temperate habits, who, whilst successfully 
but anxiously engaged in a rapidly-increasing practice, became the 
subject of severe erysipelas, upon the subsidence of which he had an 
attack of delirium, with all the most characteristic signs of delirium 
tremens. 

The diagnosis of delirium tremens, in its perfect form, is not dif- 
ficult: from phrenitis it maybe distinguished by the softer pulse, the 
moist tongue, perspiring skin, scanty urine, and by what is perhaps 
a still more important sign, the dilated pupil : from acute mania it is 
to be distinguished mainly by the character of the delirium, which is 



DIAGNOSIS — PROGNOSIS — TREATMENT. 445 

never of the violent character which it assumes in the latter disease, 
and by the state of the pupil above alluded to ; neither does delirium 
tremens assume the severe paroxysmal character. Whilst, however, 
we maintain that there is little difficulty in the diagnosis of delirium 
tremens, in its unmixed form, we would strongly inculcate, what the 
experience of all must confirm, that the majority of cases with which 
we have to do are not such; but that they seem to belong to an in- 
termediate condition, between phrenitis on the one hand, and delirium 
tremens on the other ; and it is in appreciating the tendency which 
exists to either of these affections that the tact of the practitioner will 
be particularly tried. The history of the disease will not, on such 
occasions, be always found a sufficient guide ; for not only may de- 
lirium tremens arise, though rarely, without intemperance, but what 
is more common, intemperance may induce either phrenitis or mania ; 
it is, indeed, by their characteristic symptoms that we judge of the 
presence of either of these complications, and when the probability 
of such complication existing is fully appreciated, there will be no 
great difficulty in detecting it ; thus, if with the delusion, and tremor 
of delirium tremens, we find a dry, or even not moist, tongue, a 
harsh skin, scanty urine, or a contracted pupil ; or if the pulse be 
small and hard, rather than of the full, soft character belonging to 
delirium tremens, we must regard the case as complicated, and our 
prognosis and treatment must be regulated accordingly. On the 
other hand, with many of the constitutional symptoms of delirium 
tremens, we may have the furious and paroxysmal delirium of acute 
mania. 

The prognosis of delirium tremens must, it is obvious from what 
has been said, be doubtful. In a first attack, where there are no 
complications and no very severe visceral disorder, the patient will 
generally do well. Where the symptoms of phrenitis are mixed up 
with those of delirium the danger is greater, nearly in the direct pro- 
portion of the amount of phrenitic symptoms. Those cases which 
arise from purely mental excitement independently of intemperance 
are specially dangerous. 

When we have to deal with a case of simple delirium tremens, our 
treatment must be simple and decided. The patient must be put to 
bed, carefully watched, and kept there by gentle means ; the head 
majr be shaved, or, if this be not done, the hair must be cut short ; 
and where there is undue heat of scalp, a cold or evaporating lotion 
must be applied. We must first take care that the bowels are well 
cleared out, which will be best effected by half an ounce of castor oil, 
or some rhubarb and calomel ; and when this has been done, we may 
put the patient upon the use of calomel and opium, a grain of each 
being administered every three or four hours at the commencement, 
but should this not be sufficient to quiet the excitement, an extra 
dose of opium, in the form of half a drachm of the tincture, may be 
administered at night, and this may be repeated in the course of two 
hours, should rest not be obtained. Should this fail, and should there 
be no symptoms of the unfavorable action of the opium, as indicated 
by a dry skin, scanty urine, or, what is most important of all, a eon- 



446 DELIRIUM TREMENS. 

tracted pupil, the opium may be repeated on the following night in 
still larger doses; indeed, when we have a clear case of delirium 
tremens, we must measure the dose of opium not by quantity, but by 
its effects. In the more mixed cases, however, and they are not the 
least common, more caution is necessary, and it will be safest, after 
unloading the bowels, to commence our treatment with a combination 
of calomel, camphor, and henbane (F. 84);* and, if there be much 
restlessness, with a pupil inclined to be contracted, a full dose of hen- 
bane may be given at night in the form of tincture, adding to it some 
ammonia when the pulse is feeble (F. 85). f Cases of this kind some- 
times go on favourably under the above plan of treatment, but it 
sometimes happens, that under its influence the more phrenitic symp- 
toms subside, and the disease becomes one of decided delirium 
tremens, when a full dose of opium will be followed by the best re- 
sults. Another important question in the treatment of delirium 
tremens, is the extent to which alcoholic stimulants are to be em- 
ployed. As has been observed above, the immediate cause of the 
disease appears in some instances to be the withdrawal of such stimu- 
lants, and therefore their use is clearly indicated, and generally it 
will be best to employ that to which the patient has been most 
accustomed. It is, however, to be borne in mind, that alcohol is not 
the cure for this disease, its use being to obviate that state of the 
nervous system which supervenes in drunkards when the stimulating 
effects of drink have subsided, and which may often be witnessed in 
the gin-drinker before he has had his morning-glass, and which 
favours the development of delirium tremens. The rules by which 
we must be guided in its use are nearly the same as those which 
regulate the employment of opium, except that in this case, we must 
look more to the state of the circulation, whereas in the use of opium, 
we are guided more by that of the nervous system, a compressible 
pulse being our best indication for the administering of beer, wine, 
or spirits. 

In those cases which are the result of mental excitement and anxi- 
ety, more caution is required, and we must be still more guarded in 
our use of opium : and alcholic stimulants will be less rarely admissi- 
ble. Under these circumstances, the combination of calomel and 
henbane will be our best internal remedy, and the henbane may be 
further administered in the form of tincture, in the intervals, some- 
times with the addition of Liq. Ammon. Acetatis, if there be not free 

* (84) R. Hydrarg. Chlorid._ 

Camphors Rasse, aa gr. j. 
Ext. Hyoscy. gr. iij. 
Ft. Pil. ; to be taken every four hours, 

f (85) R. Camphorse, gr. ij. 

Ammon. Sesquicarb. gr. iv. 
Tinct. Hyoscy. 
Tinct. Lupuli, 
Syrupi Aurant.. 
Mist. Acac. aa g j. 
Mist. Camphorse, ^ j. 
Ft. Haust. : to be taken at bed time. 



ACUTE MANIA. 447 

perspiration ; and in such cases, after we see our way more clearly to 
the use of opium, we may endeavour to calm the nervous excite- 
ment, and, it may be, counteract the ill effects of opium, by the con- 
tinuance of the hyoscyamus. Here also, as in most cases, the best 
guide for the use of opium is the state of the pupil. 



MANIA. 

Acute mania is another form of purely nervine disease, in which 
the affection of the brain appears mainly, if not entirely, by its func- 
tional derangement ; structural lesions when they occur being in 
most instances to be regarded in the light of effects, rather than 
causes. Though mania is characterised by attacks of furious deli- 
rium, coming on in paroxysms, it is sometimes preceded more or 
less by constitutional disturbance, not of a febrile character, but affect- 
ing mainly the digestive organs; there is generally dyspepsia, and 
sometimes jaundice, for a considerable period. The principal 
changes however, are in the nervine functions ; and it is, perhaps, 
characteristic of the disease, that this derangement is beyond all 
proportion to any bodily disorder. The first premonitory symptoms 
are often a change of manner and of tastes on the part of the patient, 
with considerable waywardness and capriciousness, he becomes unu- 
sually irrascible, or oppressed with anxieties about his temporal or 
spiritual welfare. His friends, though surprised and annoyed at this 
alteration, may entertain no serious apprehension, owing to the 
absence of much constitutional ailment, when suddenly he breaks 
out into a state of furious madness, and sometimes can be only for- 
cibly prevented doing some serious injury to himself or others. 
This state of violence may as suddenly subside into one of sullenness 
and moroseness, or he may even become for a time rational and 
tranquil, though this interval of remission will be again followed by 
a recurrence of the madness. When the disease has thus manifested 
itself, the pulse is generally quick, sometimes full, the bowels torpid, 
the urine scanty, and the tongue white, and, as it advances, it becomes 
brown. The pupils are most commonly contracted, and there is 
extreme sleeplessness. These paroxysms of excitement, with inter- 
vals, may continue to follow each other, unless we can succed in sub- 
duing them, till the patient either sinks exhausted, or passes into a 
state of confirmed insanity. 

As regards the causes of this disease, there can be no doubt that 
some are born with a susceptibility to it, inherited, it may be, through 
either parent; and sometimes this susceptibility is such, that the 
mania is excited by almost unappreciable causes; and the tendency 
is much increased by an habitually torpid state of bowels, by de- 
rangement in the digestive organs, or of the liver or kidneys. The 
more immediate causes are generally either excessive mental exer- 
tion, excitement, depression, intemperance, or venereal exeesses. 

The diagnosis of mania depends upon the character of the delirium, 
and the absence of constitutional or bodily disease in any degree com- 



44:8 ACUTE MANIA. 

mensurate with the mental disturbance; by trie former it may be 
distinguished from delirium tremens, and by the latter from phre- 
nitis. 

In mania, the delirium is more furious, and the delusions are 
more subjective than in delirium tremens, in which disease they are 
more of an objective character ; whilst there is no attempt at violence 
to others, unless under an apprehension of danger; the tremor, also, 
of delirium tremens is wanting in mania. 

The prognosis of mania is, in a great degree, dependent upon the 
cause of the disease. Where there is hereditary tendency, the pro- 
bability of recovery is less than where the disease has been induced, 
though it should be observed, that in the latter case, the immediate 
danger to the life of the patient is not less than in the former. The 
risk both of life and reason is also greater in a second than in a first 
attack, and the more frequent the recurrence, the less the chance of 
the removal of the disease. 

The treatment of the disease must consist, in the first instance, of 
endeavouring to subdue the excitement, both of the vascular and 
nervous systems; as the latter generally preponderates, our chief 
attention must be directed to it; though, it must be confessed that 
our power over the nervous, is much less than over the circulatory 
organs. When there is decided heat of scalp, the pulse strong, and 
the constitution sound, blood should be taken, either from the arm, 
or by cupping at the nape of the neck. The head, also, should be 
immediately shaved, and cold lotions, or powdered ice in bladders, 
applied to the scalp ; and, as the bowels are generally torpid, we 
must have recourse to active aperients ; calomel and colocynth should 
be administered at once in full doses ; and an active purgative draught 
shortly afterwards. The enema with oil of turpentine has an addi- 
tional good effect, not only as a purgative, but also as a revulsive. 
Calomel and colocynth, or blue pill with scammony, or compound 
rhubarb pill, may also be continued twice or thrice daily; so as fairly 
to unload the bowels, and by keeping up a steady action of the intes- 
tinal canal, to stimulate the organs which pour their secretions into it, 
especially the liver. Should sleep not be procured after the above 
measures have been carried out, we must have recourse to anodynes, 
or rather to nervine sedatives, as opium is not admissible, as a general 
rule, in this disease. And here we may be allowed to remark, that 
hyoscyamus and conium are not to be regarded in the light of mild 
preparations of opium — though they are sometimes placed in the 
same category as though they might be used indiscriminately — for 
experience teaches us that the difference of their action is not so 
much one of degree, as of kind ; and therefore when a powerful 
remedy is required, and full doses of opium seem to be contra-indi- 
cated, we must not evade the difficulty by having recourse to smaller 
doses, or less active preparations, the effect of which, as far as they 
have any effect, will be injurious, but employ hyoscyamus or conium 
in powerful doses ; the draught of the former (F. 85), will be found 
very useful, omitting the ammonia when there is vascular excite- 
ment ; as will also the camphor and hyoscyamus in the form of pills. 



TREATMENT. 449 

The exhaustion which supervenes upon the repeated fits of excite- 
ment, and which sometimes appears early, must be counteracted by 
stimulants, of which perhaps the safest will be ammonia; this may 
be given in infusion of serpentaria, and where the pulse is very feeble 
a few minims of compound spirit of gether may be added. At this 
period also counter-irritation is indicated, and blisters may be applied 
to the nape of the neck, or sinapisms to the feet. 

Throughout the whole of the treatment, the utmost vigilance is 
required to prevent the patient inflicting injury either upon himself 
or those about him; care must also be taken to exclude all objects, 
as well as persons, which may be likely to cause excitement, either 
through his affections or antipathies; and on this account, friends 
whose sensibilities might be strongly excited should be forbidden 
to approach him. 



29 



450 APOPLEXY. 



XXYI. 
APOPLEXY AND PAKALYSIS. 

The simplest definition that can be given of apoplexy is, that it is 
a sudden loss or suspension of the functions of animal life, those of 
organic life remaining intact, or at least impaired only, but not 
arrested. Thus when a person falls down senseless, but not in a 
state of syncope, the action of the heart not being greatly impeded, 
he is said to be attacked with apoplexy, or for the sake of greater 
accuracy, with cerebral apoplexy. This definition, however, requires 
considerable qualification as well as extension, since it sometimes 
happens that, with the functions of animal life, those of organic life 
are also involved, and if it be to the extent of stopping them, the 
patient of course dies — it is a case of sudden death; but if upon 
examination there be found the appearance which is supposed to 
constitute *»? ^o X ^, apoplexy (extravasation of blood), in the cranium 
or spinal canal, he is said to have died of apoplexy. It happens too, 
almost always, that the functions which hold a middle place between 
animal and organic life, those, namely, of the nerves of respiration, 
are impeded, but not arrested. When the primary lesion is in the 
brain, the automatic or reflex motions in the extremities are not 
impaired, since the true spinal system is uninjured, and, accordingly, 
the lower extremities will be drawn up when the soles of the feet are 
irritated; but it may happen also that there will be sudden loss of 
power (though the case is rare) of some of the extremities, as of the 
legs, for instance, and with it the loss of the reflex or automatic 
motion ; although at the same time the sensorial functions may be 
unimpaired. In this case the primary mischief is in the spinal canal, 
and the patient is said to have spinal apoplexy. 

Perhaps the most correct definition of apoplexy in general would 
be, that it is a sudden loss of function sustained by some portion of 
the brain or spinal cord. This again is liable to being misunder- 
stood, owing to a vagueness attached to the term apoplexy; for 
instance, when a person suddenly loses the power of one extremity 
or one side, he is said to have an attack of sudden paralysis or loss 
of power, but this is not commonly called apoplexy, unless it be 
found, or there be strong reasons for believing, that there is extrava- 
sation of blood ; whereas, the sudden paralysis or loss of power may 
depend upon a variety of conditions of the nervous matter, of which 
extravasation of blood into its substance, or upon its surface, is only 
one. We see then that the obscurity which necessarily attaches to 
the pathology of the sudden and dangerous disease which is com- 
monly known as apoplexy, is further increased by the word com- 
monly employed to designate it not always being used in the same 
sense, a difficulty rendered still greater by its unfortunate adoption 
into the pathology of another region of the body by the phrase pul- 



ITS NATURE. 451 

monary apoplexy, to express extravasation into the tissne of the 
lung. 

Apoplexy makes its attack in different ways ; and Dr. Abercrom- 
bie has described three different modes of its invasion, in which he 
has been followed by Dr. Watson ; and although every particular 
case may not in all things agree with any one of the three, it will 
almost invariably do so in its more prominent features, so that the 
bearing its distinctions in mind will contribute much to a clearer 
apprehension of this most difficult part of our subject. 

In the first form of the attack the patient falls down suddenly in a 
state of profound coma, " his face is generally flushed, his pulse full 
and not frequent, sometimes below the natural standard. In some 
of these cases convulsions occur, in others rigidity and contraction 
of the muscles of the limbs on one side only." 

Of persons so attacked some die in a short time, and a large quan- 
tity of blood is found extravasated ; others die after a longer period, 
and serous effusion only, and of no great amount, is found ; and in 
some that die early, no effusion of either blood or serum. Others 
recover altogether, and no ill effects remain ; others, again, recover 
from the coma, but remain paralysed upon one side, or as it is termed 
hemiphlegic, or with defect of the power of speech, or of one of the 
senses. The paralysis may disappear after a few days, or it may 
continue for months, or years, or for life. 

If we endeavour to analyse this class of cases of apoplexy, which 
have been distinguished by Dr. Abercrombie as the primarily apop- 
lectic, we shall perceive that they consist of a sudden loss of the func- 
tions of animal life ; we have a sudden or very rapid loss of the 
powers of the brain, and death, when it takes place, is by coma, or 
death from the brain. This may be caused by rapid effusion of blood 
pressing upon the brain and destroying its powers. In other cases, 
again, we have the same symptoms, but death after a longer inter- 
val, the coma becoming more and more profound ; and in these cases 
a small amount of fluid only is found effused upon the surface of 
the brain, or into the ventricles. This effusion as such, is not suffi- 
cient in most cases to cause death, but in the majority of instances it 
is not probably the quantity of effusion, but its quality that is con- 
nected with the invasion of the coma. The serum contains urea, 
whence it is to be inferred that the same principle is circulating in 
vessels of the brain as well as throughout the system, owing to 
urasmic poisoning from disease of the kidneys. 

Of the cases which recover from the coma some are permanently 
paralysed ; and there can be little doubt that in these there is perma- 
nent injury inflicted on the nervous matter by the extravasation of 
blood from rupture of a blood-vessel. But here it will be well to 
call to mind that this rupture is in most instances the effect of dis- 
ease of the vessel, and that the vessels of the brain are more liable to 
disease than those of almost any other part of the s^ystem ; and fur- 
ther, that such disease will often be, of itself, sufficient to produce 
sudden loss of power of that portion of the nervous matter through 
which the vessels ramify ; that is to say, that disease of the cerebral 



452 APOPLEXY. 

arteries (generally in the form of thickening of the tunics with depo- 
sit of oil globules, semi-cartilaginous matter, and sometimes calcare 
ous matter) may by simple disturbance of the circulation, produce a 
loss of consciousness or of power, that is to say, coma or paralysis, 
according to the extent and situation of the nervous substance in- 
volved. It will generally happen, however, that when there is no 
further lesion the coma or paralysis will pass off, and the patient 
recover for a time at least. 

But we have still another source of obscurity and difficulty, these 
very lesions of the arteries, which give rise to secondary lesion in 
the brain, are themselves often the result of an antecedent one, which 
may of itself produce similar disturbance of the functions of the 
brain directly, and without the intervention of the disease of the 
arteries ; since one effect of the uraernic poisoning from disease of the 
kidneys, or otherwise, is sudden coma ; but disease of the arteries 
generally, and more especially those of the brain, is among the most 
common effects of uraernic poisoning. So that we may have two 
causes coexisting, either of which may be sufficient to produce apop- 
lectic symptoms, both of which may have a common antecedent 
cause, but of which one — the disease of the arteries may be the effect 
of the other — the uraemic poisoning. 

There remains, however, another anatomical condition in which 
the apoplectic symptoms require to be accounted for, and that is 
apoplexy without any appreciable structural change whatever, the 
cases of simple apoplexy of Dr. Abercrombie ; but when we bear in 
mind what has been stated of the possibility of apoplectic symptoms 
being induced by diminished supply of blood, through disease of the 
arteries, and the probability too of this being overlooked in post- 
mortem examination ; and when we take into account the cases from 
direct uraemic poisoning, of which cause of cerebral disorder Dr. 
Abercrombie could have taken but little account, we no doubt 
greatly diminish the number of cases. 

If we endeavour to analyse the causes of apoplexy we find the 
immediate ones to consist of extravasation of blood into the substance 
of the brain upon its surface, or into the ventricles ; pressure upon, 
or compression of the substance of the brain, by determination of 
blood, or an undue quantity sent to that organ ; disease of the arte- 
ries, generally of a large branch, intercepting or diminishing the 
supply of arterial blood to a large portion of one hemisphere, often 
producing or attended by softening of some portion of the nervous 
substance from impaired nutrition ; poisoning of the blood circulating 
in the brain, by retained secretion, as in the case of uraemia ; and as 
a doubtful cause we may add, simple loss of power by the brain, or 
a portion of it, constituting the true simple apoplexy of Abercrom- 
bie ; but we regard this case as doubtful, since it is difficult to find 
unexceptionable instances from which all the other causes have been 
eliminated. 

If we still further pursue the train of causation, we find that as 
the extravasation must have proceeded from ruptured vessels, so this 
rupture may have arisen in one of two ways — either the vessels may 



ITS PATHOLOGY. 4 






have been subjected to an unusual amount of distension, or, in other 
words, the blood may have been too forcibly injected into them, or 
the vessels themselves may have been diseased. In the case of dis- 
tension, again, there is room for difference in the causes. 1. The 
injecting force of the left ventricle may have been excessive. This 
may, no doubt, arise from hypertrophy of the left ventricle ; but 
there can be little doubt that too much importance is attached to this 
as a direct cause of sanguineous apoplexy, however frequently the 
two lesions may have been found to coexist. The truth being, as 
we have elsewhere pointed out, that hypertrophy is generally the 
result of a conservative effort, either to compensate for the mechani- 
cal disadvantage of dilatation, in which case there can be no increase 
in the force of the systole, or to counterbalance the obstruction pro- 
duced by disease of the valve or arteries. In the case of valvular 
obstruction the force of the systole indeed may be increased, but it is 
so only in proportion to the obstruction, and there is no increase in 
the force of the jet. In the case of regurgitation through the aortic 
valves, or disease of the large arteries, the conditions are different ; 
for, as has been elsewhere pointed out, the blood passes along them 
in jets rather than in a continuous stream, as may be perceived at 
the wrist by the so-called water-hammer, or splashing pulse, and 
each jet is more forcible in proportion as the continuity of the cur- 
rent is destroyed ; and in such case a greater degree of violence is 
sustained by some of the remoter arteries than they are normally 
exposed to, and the result may be laceration. 2. On the other hand, 
we may have a delay in the return of the blood through the veins, 
arising from obstruction in the pulmonic circulation, whether pro- 
duced by diseases of the mitral valve, or the lungs, or air passages, 
especially the latter, as in the case of chronic bronchitis ; but in such 
cases the obstructed circulation through the veins, though it must in 
time be propagated to the arteries, and does in some instances give 
rise to laceration and extravasation, yet when it is the cause of apop- 
lexy, it is so more commonly by means of pressure from engorge- 
ment of the vessels of the brain. 

Again, we may have disease of the arteries themselves : this may 
arise from several causes, the, chief of which are — advanced life, 
leading to ossinc deposits, rigidity, and lacerability of the arteries 
generally, but more particularly those of the brain; hard labour, 
which produces a nearly similar effect ; intemperance, and disease of 
the depurating organs, but more especially of the kidneys ; though 
the last mentioned cause, namely, renal disease, may be the effect of 
the previous one, [intemperance. Another form of disease of the 
cerebral arteries is aneurism, most often of the large, but sometimes 
of small branches, which may be sometimes seen without any great 
amount of disease in the arteries generally. 

The next cause of apoplexy, namely, sanguineous engorgment, is 
one, the existence of which was for a long time denied by British 
pathologists ; but the experiments of Dr. Burrows satisfactorily show 
that the arguments used to prove its impossibility are altogether incon- 
clusive. In connection with this cause of apoplexy we may notice 



454 APOPLEXY. 

the frequently adduced one of serous effusion, constituting the serous 
apoplexy of some authors ; it is, however, far from certain, and it is 
contrary to the analogy of the other serous membranes to believe, 
that the serum can be poured out with sufficient rapidity to produce 
apoplectic coma, independently of previous engorgement or ursemic 
poisoning, either of which is sufficient to account for the attack. 

A common cause of this engorgement of the brain has been pointed 
out above — namely, obstruction to the return of the blood to the 
right heart, either caused by disease of that organ, or dyspnoea from 
disease of the lungs or air passages ; but there can be little doubt 
that it may arise primarily, upon the principle of the old adage — 
u ubi stimulus ibifluxus" whether that stimulus be primary as regards 
the brain, as from mental emotion, or, it may be, gouty hyperemia 
— or secondary, from irritation elsewhere, as in the case of the 
stomach, through the medium of the pneumogastric nerve. Disease 
of the arteries, intercepting the supply of blood to any considerable 
portion of the brain, is another cause. That by this means the func- 
tions of a considerable portion of the brain are suspended, is evident 
from many cases in which there has been sudden paralysis of the 
extremity which corresponds to the portion of the brain so affected, 
and the fact has been most ingeniously and elaborately established 
by Dr. Norman Che vers; but here we meet with an instance of the 
necessity for the most scrupulous care in endeavouring to trace the 
causation of the attack, since disease of the arteries may arise from 
uraemia, which may of itself produce apoplexy, and render the vessels 
more liable to rupture — another cause of apoplexy. But there is 
still another cause, and that is softening of the brain, which may be 
the secondary effect of diseased arteries. Jt is true that this affection 
more commonly induces gradual paralysis than a sudden attack of 
apoplexy ; but there can be little doubt that it sometimes induces 
the latter, when situated in the central parts of the brain. Softening 
may take place, as. we have seen, from active inflammation, which is, 
however, generally accompanied by symptoms of that affection, and 
is then of the character of the red or yellow softening ; but it some- 
times, though very rarely, presents itself in the form of the white or 
non-inflammatory softening, as a primary lesiou. 

The last cause of apoplexy, or apoplectic coma, which we have to 
notice is poisoned blood circulating in the brain : of this the most 
notable and frequent instance is that of which we have before spoken 
under the term uroemia. And next, if not equal to that in import- 
ance, is blood overcharged with carbon, which state may be either 
the direct effect of dyspnoea from pulmonic disease, or it may be a 
secondary effect of disease of the brain, paralysing the muscles con- 
cerned in respiration. But the same symptoms may arise from 
poisons introduced into the system by the mouth, as in the case of 
ordinary drunkenness, though the latter cases are not commonly 
regarded as apoplexy. 

We find then that there are a variety of causes which may induce 
apoplexy, widely differing as to the anatomical changes with which 
they are found associated. But we believe that they all resolve 



ITS PATHOLOGY. 455 

themselves into pressure, deficiency of supply of blood, solution of 
continuity, and poisoned blood. 

In regard to pressure it may be asked whether extravasation ever 
causes sufficient pressure to induce apoplexy ? Dr. Burrows gives 
some very good grounds for believing that it does not; but that the 
apoplectic coma and the extravasation are the joint effects of a com- 
mon cause, namely, hyperemia. And there can be little doubt that 
in by far the greater number of cases of extravasation, his reasoning 
is conclusive — that the extravasation, though it causes paralysis, does 
not produce apoplectic coma ; but in the second class of cases of Dr. 
Abercrombie, the cases not primarily apoplectic, it is difficult to 
account for the phenomena upon any other hypothesis than that 
which has been given, the quantity of blood extravasated becoming 
at length so great as to produce pressure upon the nervous fibre 
sufficient to induce apoplectic coma. The extravasation too, by pro- 
ducing laceration and division of the nervous substance, induces a 
suspension of the functions of the brain, which, when it involves the 
nerves of respiration, must amount to coma. 

It may perhaps be asked how it can happen that a person with a 
chronic disorder like the form of Bright's kidney, which is very apt 
to lead to coma, should so suddenly manifest the effects of a poison 
which must have been circulating in the system for a considerable 
time ? To this we can only reply, that the urea seems to be a cumu- 
lative poison, and that there is no more difficulty in believing the 
sudden effect of such a poison upon the brain than that of digitalis, 
which may have been taken for a considerable time, upon the heart. 

But after deducting these cases, there still remain others in which 
there is satisfactory evidence that no such condition either of the 
blood or vessels has existed, and that many of these are to be ex- 
plained by pressure from increased determination of the blood to the 
brain there can be no doubt, although some have denied the physical 
possibility of such a condition. Dr. Burrows has, however, not only 
shown that it is possible for the cranium to contain a greater quantity 
of blood at one time than another, but has proved it by experiment. 

Whether after all these deductions we have still to admit the 
occurrence of apoplexy from simple functional loss of power by the 
brain, independently of any of the above causes, may still be considered 
doubtful; its theoretical possibility may be admitted, but its actual 
occurrence is, to say the least, "not proven." 

The second class of cases of Dr. Abercrombie are those which he 
described as not primarily apoplectic — the coma not being the earliest 
symptom. The disease commences with sudden pain in the head — 
there is faintness, sickness, pallor, and the signs of syncope ; the 
patient does not always fall, and commonly recovers in a short time 
from all giddiness and confusion, but does not lose the pains in the 
head. After a certain time, varying from a few minutes to several 
hours, he becomes very forgetful, confused, and gradually sinks into 
coma, from which he rarely ever recovers ; sometimes in such cases 
there is paralysis, and now and then convulsion of one side, but more 
often there is neither. The cases of this class are more certainly 



456 APOPLEXY. 

fatal than the more sudden primarily apoplectic ones. Upon a con- 
sideration of the symptoms we may preceive that they are to be 
explained by the rupture of a vessel, which gives a shock to the 
system, from which it in a short time recovers; but in the mean 
while blood is steadily escaping from the ruptured vessel, which by 
its increasing pressure destroys the functions of the brain, and we 
have death from coma. In some cases in which there has been a 
considerable interval between the recovery from the first shock and 
the invasion of the comatic symptoms, it has been conjectured by Dr. 
Abercrombie, and with good reason, that a clot has formed upon the 
orifice of the open vessel, which has checked the hemorrhage for a 
time, and thereby arrested the progress of the disease, but by the 
removal of the clot the haemorrhage has recurred, and the pressure 
and consequent coma have advanced. 

In the third class of cases, the paralytic — the symptoms resembling 
those of the " primarily apoplectic" as regards their suddenness, but 
differing in respect to their not involving the consciousness — there is 
no coma. In the subsequent progress of these cases there is con- 
siderable difference ; in some the disease passes more or less quickly 
into apoplexy ; and in some, on the other hand, the patient gradually 
recovers the use of the paralysed muscles ; others again remain per- 
manently paralysed for the remainder of life ; bereft, it may be, of 
the use of one side, or with one leg or one arm paralysed, or imper- 
fect speech, or loss of vision of one eye from amaurosis, or dropping 
of one eye-lid (ptosis). When these cases prove fatal, the appearances 
after death are, as in the primarily apoplectic, inconstant ; and it is 
no more than we might expect that they should be so, the pathology 
of the two classes of cases being essentially the same, the difference 
being in the extent or part of the organ affected. 

Besides the immediate causes of apoplexy which have been men- 
tioned above, there are several conditions which render any person 
liable to apoplectic attacks, some of which may be, indeed, said to be 
the immediate cause of the disease ; among the first of these we may 
reckon hereditary predisposition. The recurrence of apoplexy in 
families is an observation too well attested to require to be insisted 
upon. Age is a most important agent in the production of apoplexy. 
It is true we sometimes meet with apoplexy in young persons, but 
after fifty the liability to it greatly increases, and a greater number 
of cases occur between the ages of fifty and sixty than in any other 
decennial period of human life. It is not, however, to be inferred 
from this that the liability to the disease begins to decrease after 
sixty, but only that the absolute number of persons living decreases ; 
and if this be taken into the account it is found that the proportion 
of those who die of apoplexy between sixty and seventy is still 
greater than in the preceding decennial period, and the same of ages 
still more advanced. The results of statistical inquiries appear to be 
that the liability to apoplexy increases as age advances, but that 
about fifty it undergoes a considerable increase. Whether the apo- 
plexies in advanced life are generally those from disease of the arteries 
or from simple engorgement has not been estimated by any author, but 



ITS REMOTE CAUSES. 457 

it is probable that the former affection increases with increasing age, 
and with it, as a necessary consequence, the tendency to apoplexy and 
paralysis. The gouty diathesis is another predisposing condition ; na- 
tural configuration and temperament is another; persons of a plethoric 
habit, corpulent, and with short necks, are more prone than others to 
this disease ; but the most spare are not exempt from it. Here again 
we most likely meet with differences in the kind of apoplexy, that is 
to say, in its immediate cause, as it is probable that the apoplexy of 
the short-necked and plethoric is that of congestion (generally venous), 
while the apoplexy of the spare is that of diseased arteries. Disease 
of the heart and respiratory organs, again, have been pointed out as 
predisposing to apoplexy; and, according to the arguments already 
adduced, it is probable that the apoplexy from disease of the mitral 
valve — of the right heart, — or that from pulmonic obstruction, from 
whatever cause arising, is the apoplexy of engorgement ; and there 
is probably a considerable difference as regards the state of the 
circulation through the brain, as well as in other parts of the body, 
between disease of the aortic orifice, and that of the mitral valve 
with the cognate condition, which difference we have already pointed 
out (280 et seq). 

Another predisposing condition, or perhaps we should rather say 
the most frequent of all the primary causes of apoplexy, is Bright's 
kidney. The series of causation, indeed, by which it produces apo- 
plexy may be various ; either it may ensue directly from the non- 
depurated blood, or through the heart disease, of which the renal 
affection is a most productive cause, or through the arteries, which 
are also very prone to become affected from the same source. 

The diagnosis of apoplexy as such is not difficult; the only diseases 
with which it is liable to be confounded are epilepsy and intoxication 
either by alcohol or opium. From the former it may be distinguished 
by the absence of the convulsions or other characteristic signs of epi- 
lepsy to be hereafter described. From intoxication the diagnosis is 
not always so easy, since profound intoxication is a species of apo- 
plexy; the previous history will in most cases enable us to recognise 
intoxication, which for our credit's sake, as well as the safety of the 
patient, it is most important that we should not set down as apoplexy : 
but when a man is found in a condition supposed to be apoplectic, 
and can give no account of himself, we must observe carefully if there 
be any smell of alcohol or opium in the breath. It is to be remem- 
bered too that either alcohol or opium might induce apoplexy, but 
it would be safer, especially in the case of alcohol, to wait for its 
development ; and in a doubtful case the use of the stomach pump 
would probably bring to light the true state of the case. 

The diagnosis of the true nature of the case, or, in other words, of 
the cerebral lesion upon which the apoplectic attack depends, requires 
much more consideration ; and as upon it must depend the treatment 
to be pursued we shall consider the two subjects together. 

There has been no more prevalent or dangerous error, or which has 
more slowly yielded to the increased accuracy of modern pathology, 
than, that all cases of apoplexy are to be met with active depletion 



458 APOPLEXY. 

and other powerful antiphlogistic measures ; whereas, from what we 
have seen, the apoplectic seizure may arise from such very different 
causes, and be connected with such very different conditions of the 
system, that it is obvious that the same remedies cannot be applicable 
to all. Let us first take as an instance an attack of the primarily 
apoplectic kind, which, from the suddenness of its invasion and the 
imminent danger of the patient, appears to require the most prompt 
treatment. Those cases which strictly agree with the description of 
Dr. Abercrombie, quoted above, in which the face is flushed and the 
pulse full and strong, are cases of active congestion of the brain, gene- 
rally with a strong left ventricle of the heart, arising either from that 
cause or simple increased determination of blood to the brain, aggra- 
vated probably by some unusual mental excitement, or the stimulus 
of excessive repletion. In such cases prompt and active depletion is 
the most appropriate remedy. A vein should be immediately opened 
and blood be allowed to flow until a decided impression is produced 
upon the pulse. The bowels should also be freely acted upon with 
the least possible delay. For this purpose, when there is no very 
great difficulty in swallowing, a full dose of calomel, say ten grains, 
should be administered, which will best be effected by mixing it with 
a little sugar and butter, and placing it far back upon the tongue of 
the patient ; but if he appear totally unable to swallow, which may 
be ascertained by introducing a tea-spoonful of liquid into the mouth, 
it will be better not to attempt to give the calomel, since it is apt 
to be rolled about in the mouth, and by producing soreness may 
increase the difficulty of deglutition without any adequate benefit. 
Under such circumstances about two drops of croton oil should be 
placed on the tongue, and in either case a purgative enema should be 
administered (F. 86).* But it very often happens that we do not find 
the concurrence of the above symptoms ; full and strong pulse and 
the flushed face may be one or both of them wanting, in which case 
the apoplectic seizure may arise either from failure of the circula- 
tion from a feeble heart, or from diseased arteries, or from pulmonic 
obstruction, uraemia. Under such circumstances, nothing can be 
more judicious than the advice of Dr. Watson, adopted too by Dr. 
Burrows. " If the pulse be full, or hard, or thrilling, or if there be 
obvious external signs of plethora about the head, blood must be 
drawn. You are not to refrain from bleeding the apoplectic patient 
because he is pale if the pulse warrants it, nor may you omit taking 
blood if the face be turgid, although the pulse be small, for that 
smallness may depend upon organic disease of the heart. On the 
contrary, if the skin is pale and cold and the pulse flickering, you 
would probably insure your patient's death if you withdraw from the 
failing heart and blood-vessels a portion of their natural stimulus." 
Though even these directions must be received with some qualifica- 
tion, since there may be other causes besides disease of the heart, 
of which the chief are diseased cerebral arteries and uraemia, which 

* (86) R. Pulv. Jalapse, 3J. 

Infus. Seance co. (callidi) § xii. Misce. 
Ft. Enema. 



DIAGNOSIS AND TEEATMENT. 459 

may produce apoplexy, in which, case large bleedings would not be 
expedient. 

In the first place, however, it is most important, as Dr. Burrows has 
pointed out, to examine carefully the state of the heart, to which we 
would add that of the large vessels. Now the state of the pulse in 
diseases of the brain and upper part of the spinal cord is very per- 
plexing, and we have alluded to the influence of such as well as of 
cardiac affections in modifying the character of the pulse at the wrist, 
but when we know that there is cerebral disease, and apprehend that 
of the heart, the necessity for careful auscultation of the latter must 
be apparent. " If," says Dr. Burrows, " no cardiac disease be dis- 
covered, or if simple hypertrophy without notable valvular disease be 
detected, depletion, both general and local, may be carried on so far 
as the cerebral symptoms appear to call for that kind of relief." But 
we would here recur to what we have stated as to the frequency of 
simple, i. e., primary hypertrophy (p. 272). A plethoric subject with 
full muscular development, and using much muscular exercise, may, 
indeed, especially after repletion, have an attack of apoplexy, and in 
such a case we should find all the conditions laid down by Dr. Wat- 
son as indicating depletion, which should be carried as far as the 
exigencies of the symptoms require, both in the way of bleeding and 
purging. But if we find hyperthrophy of the left ventricle without 
such condition and without valvular disease, we must refer it to one 
of the causes already assigned (p. 272), and regard it merely as a com- 
pensation for some other cause obstructing or impairing the force of 
the ventricular systole. If that cause exist in the left ventricle itself, 
in the way of fatty degeneration or the effects of carditis, the com- 
pensation will rarely be sufficient to counteract the obstructing cause, 
and we shall have practically a weak heart (which will generally be 
evidenced by more or less of dilatation). This will also appear in 
the feebleness of the pulse at the wrist, and still more in that of the 
pulsation of the carotids, which ought always to be most carefully 
explored. 

But, as we have pointed out, one very common cause of hypertro- 
phy is disease in the form of thickening of the tunics of the remoter 
branches of the arterial system ; and such a state of things is very 
likely to be associated with apoplexy, if not to lead to it, and per- 
haps these cases constitute the greater number of those included in 
the term simple apoplexy. This cause of hypertrophy may generally 
be detected by the signs we have already given, especially by the 
tortuous and rigid radial or temporal artery, and by any evidence we 
may have of the existence of one of its frequent causes — visceral dis- 
ease, hard labour, hard living, and advanced age. Are we to bleed 
in such cases? Now here we may have active congestion, attended 
or not by rupture of a vessel, — or a narrowed and diseased artery, 
obstructing the supply of blood ; we, in fact, may have one of two 
opposite conditions. In the case of congestion we shall generally 
have the heart acting strongly and the pulse of considerable force, 
after making allowance for the thickened arterial tunics. Under 
such circumstances we believe that, except in very advanced life, we 



460 APOPLEXY. 

may bleed moderately, more especially as in this condition of the sys- 
tem bleeding is generally well borne; and even if there be renal 
disease, which is not unlikely, it will not render the patient less able 
to bear one free venesection. But if we find hypertrophy with a 
feeble pulse, and still more, if the pulsations of the carotids are not 
strong, even though there may be no valvular disease, it is probable 
that there is some obstruction to the circulation which the hypertro- 
phy is hardly sufficient to counteract, or that the hypertrophy is of the 
right ventricle, in neither of which cases is venesection expedient; 
and where there is reason to apprehend disease of a large artery of 
an obstructive character, diminishing the momentum of the blood 
throughout a considerable portion of the brain, depletion would be 
most mischievous. In cases of apoplexy from diseased arteries 
there is generally pallor, probably from the patient being commonly 
of advanced age, and also from its frequent connection with renal 
disease ; but if the pulse be full and but little compressible (and in 
saying this we must repeat the distinction between a hard artery 
from thickened tunics and a firm pulse from a forcibly acting left 
ventricle wrth perfect valves), we may venture to bleed provided the 
extreme age of the patient do not contraindicate it ; but if the pulse 
be compressible we should do wrong, although we may have evidence 
by auscultation of hypertrophy ; still more, as in the absence of val- 
vular disease, and with a small pulse, it would be more than doubtful 
that the hypertrophy was of the left ventricle. 

As regards well-marked disease of the large arteries, we would lay 
it down as a rule that venesection should never be resorted to; but 
if there be considerable arterial action, cupping may be employed 
between the shoulders ; but even this remedy must be employed with 
caution, since these are the cases in which we are most likely to have 
anaemia of a portion of the brain from obstructive arterial disease. 
In such cases, however, we shall almost always have hemiplegia. 

If there be regurgitation through the aortic valves, the thrilling 
pulse and forcible impulse of the heart, which will be generally 
hypertrophied, as well as dilated, should never tempt us to abstract 
blood by venesection, and if there be only obstruction in these valves 
without regurgitation, the same rule applies, since though there will 
probably be hypertrophy, this hypertrophy will not be more than 
sufficient to overcome the obstruction ; in neither case, however, does 
apoplexy occur so much as the direct result of the hypertrophy as 
from the obstruction being propagated through the lungs to the right 
side of the heart, and bringing the circulation to the condition in 
which it is when there is disease of the mitral valve : in which case 
the pulse, as we have before pointed out, is too feeble or irregular to 
suggest the idea of venesection; so that all the forms of valvular 
disease ordinarily met with, fall into the same category as regards 
the state of the cerebral circulation, and this last is similar to that 
produced by emphysema of the lungs, or dilatation of the tubes from 
chronic bronchitis ; the similarity of which latter affection, as regards 
the circulation, to that produced by disease of the mitral valve we 
before pointed out (p. 282). In all these cases there will be evidence 



TEEATME-NT. 461 

of extreme congestion, with forcible action of the heart ; bnt a know- 
ledge of the mechanical disadvantage at which that organ is acting, 
should deter us from venesection, thought great relief will often be 
afforded by the free local abstraction of blood, by cupping either 
between the shoulders, under the left mamma, or at the scorbiculis 
cordis. 

In all these cases, too, as we pointed out in disease of the heart 
producing venous congestion, much relief will be obtained by the 
free use of purgatives. Diuretics of a somewhat stimulating charac- 
ter will be found a valuable adjunct to the treatment, more particu- 
larly, as pointed out by Dr. Burrows, in cases proceeding from pul- 
monic obstruction : in those where the circulation is feeble the pur- 
gatives also should be of a somewhat stimulating character (F. 87),* 
and the enema should contain about an ounce of oil of turpentine. 
A blister should also be applied to the nape of the neck, and this, 
too, should be done in those cases where even local depletion is not 
admissible. When there is dilatation of the chambers of the heart, 
or the circulation is very feeble, and the patient anaemic, we must 
not be deterred by the name of .the disease from the use of stimu- 
lants, either in the form of ammonia, or it may be wine or brandy, 
especially if the extremities are cold and clammy, and the skin 
bedewed with perspiration ; and these may often be required imme- 
diately after local depletion, in cases where the latter has been 
deemed necessary from the signs of excessive congestion. But the 
primary apoplectic cases include those in which there supervenes a 
sudden profound stupor, sometimes with convulsion, but more com- 
monly without it, in which there is no evident paralysis, and in 
which there is reason, either from examination of the urine, or from 
other sources of information, to believe that there is albuminuria: 
when this is the case, and the coma is the direct effect of the urea 
upon the brain, as shown by the character of the stupor and the 
absence of any of the other lesions which we have pointed out as 
inducing apoplexy; venesection is not indicated for the relief of the 
disease as such, but if there be increased arterial action, especially in 
the carotids, blood may be taken; it is however generally better to 
do so by cupping than by opening a vein ; though if there be much 
hypertrophy of the heart, the latter is admissible. The bowels must 
also be promptly acted upon, both by purgatives by the mouth and 
by enemata; for the former purpose not more than a single dose of 
calomel of about five grains is allowable, and that should not be 
repeated, on account of the great susceptibility of the system to the 
action of that mineral. 

The second class of cases (those not primarily apoplectic) may 
generally be recognised by the peculiar mode of invasion of the dis- 
ease ; and here unfortunately we can do but little, as the prognosis is 
in the highest degree unfavourable, the sudden pain generally indi- 

* (87) R. Pulv. Rhei, gr. x. 

Decoct. Aloes co. 3 ss. 
Infus. Sennre co. 5 j. Misce. 
Ft. Haust. ; to be repented every third or fourth hour. 



462 APOPLEXY. 

eating that a vessel of some size has given way in the brain, or on 
its surface, and the subequent coma is the result of the pressure pro- 
duced upon that organ. These are generally the cases of aneurism 
of one of the arteries of the brain already alluded to ; and the ques- 
tion arises as to whether the coma is due directly to the pressure of 
the effused blood, or mediately to an anaemic condition of the brain 
which that pressure must tend to produce. In the former case, it is 
desirable to diminish as much as possible the force of the heart's 
action; in the latter, the abstraction of blood would be injurious. 
The best guides under these circumstances are — the force of the 
heart's action, carefully distinguishing between the stronger impulse 
with a rather deep sound, of a hypertrophic ventricle, and the heaving 
beat with clear sound of a dilated one ; — the pulse at the wrist, taking 
especial notice of its being firm, perhaps slow, or on the other hand 
compressible and "splashing;" — the countenance whether congested 
or pallid. Of these perhaps the most important is the pulse, and if 
that be of the latter character, the depletion ought on no account to 
be had recourse to. If the patient be seen early, and the signs of 
oppression with strong cardiac action exist, the attempt should be 
made to check the mischief by venesection, carefully watching its 
effects upon the pulse. In the more intermediate condition, when 
the pulse is still firm, and the countenance turgid, blood may be 
taken from the nape of the neck by cupping, but where there is the 
hemorrhagic pulse and pale countenance, we should rather have 
recourse to gentle stimulants. 

The treatment of the third class, or paralytic cases, must be regu- 
lated upon the same principles as those of the first, with the excep- 
tion that as we have not in the first instance to contend with the 
coma, there will not therefore be such urgent necessity for depletion ; 
but we must be guided in its use by the same rules as in the pri- 
marily apoplectic cases, with the additional reason against venesec- 
tion that in the case of hyperaemia this has been already followed by 
extravasation, and therefore one great reason for the use of the lancet 
will have been removed; when therefore there are indications for 
the abstraction of blood in the condition of the heart, the pulse, or 
the countenance, or when there is pain in the head over the mastoid 
process, or on the temple, on the opposite side to that which is par- 
alysed, we should prefer cupping from the nape of the neck. A con- 
siderable proportion of the cases of sudden paralysis, especially if it 
is partial, affecting, for instance, only one extremity, or the tongue 
or muscles of one eye, depend upon obstructed circulation from dis- 
ease of the arteries supplying the corresponding portions of the 
opposite side of the brain. To the diagnosis of this condition we 
may be led by the state of the temporal arteries, the age and habits 
of the patient, and the character of the urine. General depletion will 
here be scarcely ever required; but if the action of the heart be 
forcible, blood may be taken by cupping from the nape of the neck ; 
and if there be signs of congestion, but with a doubtful state of the 
heart, considerable relief will be obtained by dry cupping. After 
this a blister may be applied, and a moderate dose of calomel admin- 



TREATMENT. 463 

istered (when the iirine is not albuminous), and the action of the 
bowels kept up by purgatives of a somewhat tonic character, such 
as the rhubarb and compound decoction of aloes. 

Sudden paralysis may sometimes ensue from softening of the brain, 
the suddenness of the attack depending probably upon the rapid 
extension of the disease to a set of fibres influencing the voluntary 
power of the affected muscles. This is generally associated with the 
arterial disease just specified, and will present no signs of increased 
vascular action, but often the opposite. Under such circumstances 
stimulants may be carefully administered, the bowels being kept 
freely open, but not purged, and a blister applied to the nape of the 
neck, and subsequently to the side of the head opposite to that on 
which the paralysis exists. The paralysis may, as we have observed, 
be brought about by the extension of softening, but this extension 
may also reach the more central parts of the brain, and, by implica- 
ting the origin of the nerves of respiration, induce apoplectic coma : 
or the arterial disease which has lead to softening may also bring- 
on apoplexy by the giving way of one of the diseased vessels. In 
either case of apoplexy supervening upon paralysis, the prognosis is 
highly unfavourable, and the treatment must be the same, and 
regulated upon the same principles as that of the second class of 
cases. 

After the " fit," as it is termed, of apoplexy has passed off, and 
more particularly in those cases where it is followed by hemiplegia, 
and pipbably attended by extravasation, inflammatory change takes 
place around the clot: and two or three days after the coma has sub- 
sided the patient complains of pain in the head, generally on the side 
opposite that which is paralysed ; the face becomes flushed, the scalp 
hot, the patient frowns, and sometimes squints ; sometimes there is 
spasm of the arm or leg on the paralysed side, the arm being often 
drawn firmly across the chest ; these muscular efforts being, as Dr- 
Burrows observes, an effect of the irritation produced by the clot in 
the cerebral substance around it ; there is, at the same time, more or 
less pyrexia. Under these circumstances antiphlogistic measures are 
called for ; but they should not be of a violent character. The 
patient should be cupped at the back of the neck, and salines with 
antimonials may be employed for a time, the bowels being kept 
freely open; after the skin has become cooler and moist, bichloride 
of mercury will often be of service ; a drachm of the solution may be 
given three times a day, and the dose increased to a drachm and a 
half, or two drachms. A good form for its exhibition is the well- 
known one of Sir A. Cooper (F. 88).* Counter-irritation should be 
at the same time used. After, however, the inflammatory symptoms 
have passed away, and in some cases where none have existed, the 
paralysis continues, and sometimes the patient complains much of 
pain in the affected limbs ; for the latter we cannot often do much, 

* (88) R. Liq. Hydr. Bichlorid. 5 ss. 
Tinct. Rhei, 

Tinct. Cinchonoe, aa £ ij. Misce. 
Of which 3; j. to iij. is to he taken in any proper vehicle. 



46-i APOPLEXY AND PARALYSIS. 

but some relief may be given by anodyne and gently stimulating 
liniments : as regards either, we can do but little towards the remo- 
val of the primary lesion ; yet where the paralysis is not perfect, and 
there seems to be some return of power, though it may take place 
slowly, we may help the progress of the patient by nervine tonics, of 
which the safest and most efficient is the sulphate of zinc, which may 
be given, beginning in doses of a grain, increased to four or five, 
three times a day. 

We have already alluded to apoplexy of the spinal marrow : that 
is to say, — sudden abolition of its proper functions. This may some- 
times arise from spinal haemorrhage, the symptoms of which are sud- 
den pain in some part of the spinal cord, convulsions, and paralysis 
of those parts below the seat of the injury. Such cases are very 
rare ; at least as observed by the morbid anatomist, the cases which 
he records being the fatal ones : but it is not improbable that slight 
extravasations do occassionally take place, and produce paralysis, 
which is recovered from. 

This paralysis of the lower extremities, commonly known by the 
term jparaphlegia, may, however, arise from other causes, some of 
which are very obscure. The functions of the spinal cord may, 
besides extravasation, be arrested by softening, whether inflammatory 
or otherwise, by effusions or thickening, arising from inflammation 
of the membranes, or by pressure from tumours, or disease, or dis- 
placement of the vertebrae ; but in many cases there can be found no 
lesion to account for the paralysis, and we are driven to the conclu- 
sion that there is such a thing as loss of nervous power without any 
change in the nervous matter which we are at present able to detect. 
In some cases the palsy comes on rather suddenly ; the patient com- 
plains perhaps for a time of pains in some part of the spinal column, and 
then has suddenly an increase of this pain, with loss of power of the 
lower extremities. In the majority of cases, however, the disease 
creeps on far more insidiously ; there is a feeling of diminished 
power and increased weight in the legs, which are apt to become 
colder than in health ; there is tingling and numbness of the toes and 
feet, and a feeling of irritation as if by ants, which has received the 
name of formication : the difficulty of walking increases, and ulti- 
mately the patient loses altogether the power of doing so. The 
paralysis gradually extends in this way from below upwards, affects 
the bladder and rectum, and ultimately some of the organs still more 
essential to the maintenance of life, the patient sometimes dying of 
apnoea from paralysis of the muscles of respiration. In some of these 
cases no structural changes can be found in either the brain or spinal 
cord ; of such changes the commonest is softening. 

In the majority of instances the seat of the disease would appear 
to be rather in the brain and its prolongation into the spinal canal 
than in the true spinal marrow itself; since when the voluntary 
power is almost entirely annihilated, the reflex or excito-motory 
functions evince even a more than ordinary amount of susceptibility, 
the legs being often forcibly retracted when the feet have been irri- 
tated ; this circumstance has formerly led to the belief that patients 



PAKAPLEGIA. 465 

were malingering, it having been assumed that if a person withdrew 
the foot from being tickled or pricked, and sometimes from even 
harsher irritation, he could move it at other times if he would. 

The lesion upon which paraplegia depends may be, as we have 
seen, various, and in some there is no appreciable structural lesion 
whatever, the disease being, in the strictest sense of the word, nervine, 
or depending upon failure of that power of which the nervous mat- 
ter as regards its physical constitution is the vehicle rather than the 
cause. In some instances, independently of those in which the disease 
originates in the nervous centres themselves, the loss of power is 
produced through injury inflicted directly upon the extremities of 
the motor nerves, as by exposure to cold ; attacks of paraplegia 
sometimes come on after a person has left a warm room, and gone 
out upon cold ground with the feet and legs thinly covered, or when 
a person has been long sitting or standing with the legs and feet cold 
and wet ; sometimes severe injury to the extremities of the nerves, 
probably of the sentient ones, has resulted in structural changes of 
the nervous centres, and subsequent paralysis, as in a case which 
occurred to the author in Guy's Hospital. Coexisting gastric irrita- 
tion has by some been thought a sufficient cause of paralysis of the 
lower extremities, and probably such is sometimes the case in chil- 
dren. The same has been said of disease of the kidneys, and 
certainly cases do occur of paraplegia coincident with strumous dis- 
organisation of those organs. It must be remembered that in most 
cases of paraplegia the urine is alkaline, though there is some obscu- 
rity as to the cause in such instances. Probably, however, this 
alkalescence has its being in a conservative effort of nature, large 
quantities of mucus (which is always alkaline) being formed to pro- 
tect the bladder from irritation by the retained urine. In such cases, 
too, the bladder presents all the appearances produced by chronic 
inflammation. 

In the treatment of paraplegia we must, in a great measure, be 
guided by the nature of the primary lesion as far as we are enabled 
to detect it. In those cases where the paraplegia has followed 
closely upon symptoms of inflammation of the cord and its mem- 
branes, we must employ local depletion, and antiphlogistic regimen, 
and a gentle mercurial course, though the latter should be used with 
extreme caution when we suspect that there may be softening of a 
non-inflammatory character. These cases again which are consequent 
upon exposure to cold are commonly of an inflammatory character, 
the immediate cause being often the pressure from effusion of fluid 
within the spinal canal, which effusion may have originated there, or 
have descended from the cranium. In the cases of which we are 
speaking the former is most probably the case, and here the abstrac- 
tion of a small amount of blood, followed by counter-irritation along 
the course of the spine, with a gentle mercurial course, should be 
first employed. A good form for the mercurial will be the Pil. 
hydrarg. ; or if the bowels are not sluggish, the combination' of hydr. 
cum cret. and pulv. ipecac, co., and subsequently iodide of potassium. 
"When the debility continues, the sulphate of zinc may be used, as 

30 



466 FACIAL PAKALYSIS. 

in the former cases, and electric sparks may be passed from the 
spine to the lower extremities, or an electro-magnetic current passed 
along the same course. Those cases which come on more gradually, 
and appear to depend sometimes upon adynamic softening, and at 
others seem to be unconnected with any structural change whatever, 
are even still less amenable to remedies than the preceding : where, 
however, the structural lesion may have originated in inflammatory 
action or even excitement, the bichloride of mercury may be used 
in the form already recommended. Subsequently tonics should be 
used, of which the best is the zinc, which may be pushed to doses of 
ten or twelve grains three times a day ; or the syrup of the iodide 
may be employed, commencing in doses of half a drachm, and in- 
creased to a drachm and a half, or two drachms. In all these cases 
the bladder must be carefully attended to. Sometimes there is 
incontinence of urine, but at others retention ; and as we have before 
pointed out, the bladder is apt to become inflamed and irritated by 
the retained secretion, and, what is more, the pelves of the kidneys 
distended, leading sometimes to disorganisation of these organs, or 
to a suppression of their functions, which tends greatly to aggravate 
any pre-existing nervine diseases. The urine should therefore be 
drawn off at least twice in the day when there is retention, and, if 
necessary, the bladder washed out with warm water. 

Besides the above, there are other forms of partial paralysis of the 
nerves, both of motion and sensation, frequently met with ; the latter 
generally denominated ancesthesia. From a privative and cufjflavo^ai., 
I perceive. 

Of the different forms of local paralysis, there is none more fre- 
quently met with, or of greater practical importance, than is that of 
one side of the face, generally known as facial paralysis, or paralysis 
of the portio dura, the muscles supplied by that portion of the seventh 
pair being generally, though not always, those which are exclusively 
affected: it is sometimes, too, known as Bell's paralysis, from the 
great pfrysiologist Sir Charles Bell, to whose discoveries we are 
indebted for a knowledge of its true nature. With this facial para- 
lysis we may have facial ancesthesia, and it is well to consider the two 
together, though when the latter is superadded the affection is a far 
more serious one. 

We have before alluded to paralysis of the muscles of one side of 
the face as a part of hemiplegia, and whenever we meet with this 
form of paralysis, we must examine carefully whether either extremity 
or any other part is similarly affected, and if we find that it is not, 
we may be able to remove much serious apprehension that may be 
entertained by the patient or his friends. 

The facial palsy sometimes comes on very suddenly, the muscles 
of one side of the face becoming, as it were, powerless and sleeping, 
whilst those of the opposite side retain their wonted expressiveness. 
This Avant of symmetry is increased, too, by the mouth being drawn 
somewhat to the unaffected side. When, however, the patient speaks, 
or smiles, or weeps, the difference becomes still more striking, the 
unaffected muscles, no longer counterpoised by those which should 



TREATMENT. 467 

antagonise them on the opposite side, draw the mouth still more to 
the unaffected side ; at the same time that the contrast between 
sleeping or waking, or between life and death, in the visage of the 
same person is at once ludicrous and distressing. Fortunately, the 
majority of these cases are more frightful to the uninitiated than 
really dangerous in the estimation of the experienced, provided that 
the paralysis be confined to the muscles supplied by the portio-dura. 
The paralysis of these muscles is rendered still more apparent by 
desiring the patient to blow or whistle, when the muscles of the 
paralysed cheek are puffed out like a foot-ball ; or to close the eyes, 
when that of the paralysed side remains partially open, with the 
pupil drawn upwards ; and whilst the brow of the sound side is some- 
what contracted by the action of the orbicularis oculi, that on the 
affected side remains smooth and undisturbed. With all this, how- 
ever, the power of the temporal and masseter muscles, which are 
those of mastication, and supplied by the fifth nerve, remains unim- 
paired. Curiously differing from these cases are those of facial 
anaesthesia; here the fifth is the nerve involved, and the loss of 
sensation is in most cases perfect over one side of the face, terminat- 
ing, to a nicety, at the median line, so that even the most sensitive 
part, as the surface of the eye, may be touched without its being felt 
by the patient ; the sense too of taste, as well as of feeling, of the half 
of the mouth is lost on the affected side. All this time, however, 
the power of voluntary motion is unimpaired as regards the acts of 
speaking, breathing, expression, and the like, and the symmetry of 
the visage is undisturbed ; but in the act of mastication the case is 
different. When the patient attempts to perform it the temporal and 
masseter muscles are found to be powerless on the side which has 
lost its feeling. 

We have just seen in striking contrast the effects of loss of their 
proper functions by the two nerves mainly supplying the muscles 
and other textures of the face and mouth, the fifth and the portio- 
dura. Now the cause of this loss of function may be seated either 
within the cranium, or along the course of the respective nerves. 
When the portio-dura alone is implicated, it is probable that this 
cause is either in the bony canal, in the temporal bone, or in that 
part of the nerve which lies in front of the ear. When, on the other 
hand, it becomes apparent from the extent of the anaesthesia, and 
loss of power of the muscles of mastication that the whole of the 
fifth nerve on one side is affected ; it follows from the more com- 
plicated origin, as well as distribution of that nerve, that the disease 
must be within the cranium, and therefore the prognosis becomes 
much more unfavourable (unless, indeed, one branch only of the fifth 
be implicated). 

The circumstances which may cause facial paralysis are of course 
exceedingly various, and it is only by careful examination of the 
course of the nerve that we can ascertain whether there be any 
tumour or other mechanical cause pressing upon the nerve and ob- 
structing its functions, or whether the patient have received any blow 
or other injury which may have produced the same result. We 



468 SPASMODIC DISEASES. 

must inquire also for any evidence of disease in the ear; but when all 
these causes have been eliminated, there remains the most frequent, 
which is exposure to a current of cold air ; and when there is a 
history of such an occurrence, and the case is one of simple facial 
paralysis, we may in most cases encourage our patient with the hope 
of perfect recovery. When, however, there has been any thickening 
of the sheath or parts around the nerve, we must expect more or less 
permanent deformity ; but even here we may give the patient the 
comforting assurance that this is the extent of the mischief. 

When, from the history of the case, it appears that there has been 
a blow or exposure to cold, or other causes of inflammatory action, 
we must have recourse to either general or local ' depletion ; the 
former being indicated when there are the constitutional signs of 
inflammatory fever well marked. In other cases local abstraction of 
blood, as by cupping behind the ear, is to be preferred ; apply fomen- 
tations to the ear, or, what Dr. Watson recommends as still better, 
direct a current of the steam of hot water against and into the ear. 
Mercury should also be administered so as slightly to touch the 
mouth, and afterwards, especially if there be thickening or indura- 
tion, iodide of potassium should be given. When there are signs of 
extensive disease in the petrous portion of the temporal bone, we 
cannot expect much benefit from any active treatment whatever. 

The cases of facial anesthesia belong, as far as treatment is con- 
cerned, to the same class as other instances of loss of function of the 
nerves ; such partial paralyses are, it is to be remembered, often 
amongst the first signs of softening of the brain, especially in persons 
whose nervine power has been impaired by intemperance or other 
excesses, fatigue of body, or mental anxiety, or too great intellectual 
exertion. In such instances, after using gentle measures to subdue 
any inflammatory excitement that may exist, but not unless we have 
good proof that it does exist, mercury in the form of bichloride may 
be employed ; but in cases non-inflammatory, mercury, especially 
if it produce ptyalism, is most injurious. Iodine may, however, be 
employed in the form either of iodide of potassium, or iodide of zinc ; 
but most reliance may be put upon a full course of sulphate of zinc. 



SPxiSMODIC DISEASES. 

Hitherto we have spoken either of structural changes producing 
diminution of the functions of the nervous substance, or total aboli- 
tion of it, or of those instances in which this power has appeared to 
be suspended or destroyed independently of any appreciable change 
in the nervous matter; but we have only incidentally alluded to that 
most remarkable condition, spasm. Spasm may be said to be the 
opposite of palsy; it is an excess of muscular force, and that, too, 
excited in a perverted and disorderly manner. 

There are two kinds of spasm, the one consisting of long-continued 
contraction of the affected muscles, which slowly and imperfectly 
relax, and then, after a time become again contracted ; this is termed 



SPASM — ITS NATURE. 469 

tonic spasm. In the other, which is termed clonic spasm, the con- 
tractions are sudden, violent, and repeated, the intervening relaxa- 
tion being, of course, equally sudden and repeated. In many 
instances antagonising muscles seem to be alternately affected, so 
that a limb is thrown into continued and forcible jactitation, during 
what is termed a "fit" of this kind of spasm. 

We have before had occasion to remark, that the excito-motory 
functions may be in full activity, when those of voluntary motion 
are suspended, or destroyed by disease; and. more than this, we 
often find the former increasing in activity in proportion as the 
latter become impaired; of this we have an instance in the case 
recorded by Dr. Watson, of a gentleman who at the commencement 
of an attack of paraplegia, found that when he attempted to scrape 
his foot on the scraper at the house-door, his leg and thigh were 
forcibly and involuntarily flexed and drawn upwards. And we may 
observe that, independently of disease, the energy of these two func- 
tions seem to vary in an inverse proportion. Thus in infancy, when 
the voluntary power is as yet undeveloped, the excito-motory is in 
the fullest activity ; and, although we may not observe any inconve- 
nient defect of excito-motory power, where the voluntary is in per- 
fection, yet we do not commonly find in the robust, vigorous man 
that liability to sudden movements of the voluntary muscles, inde- 
pendently of their natural stimulus, viz., volition, which is so fre- 
quent in the delicate female; he is not so "nervous" in fact. When, 
then, the voluntary power of the brain is least energetic, the volun- 
tary muscles, which in perfect health in the adult subject are mainly 
under its influence and but little subject to the true spinal system, 
become almost entirely under the control of the latter; and conse- 
quently, strong, muscular contortions are excited upon the applica- 
tion of the lightest stimuli, and which are quite beyond the control 
of the will. Dr. Todd has not inaptly applied the term polarity to 
this power of the spinal chord of generating power within itself, to 
be communicated to the voluntary muscles ; and if, we apply, as we 
not unreasonably might, the same term to the power of the brain of 
originating voluntary motor power, under the influence of volition, 
we might lay it down as an aphorism, the result of observation, that 
the polarity of the spinal cord varies in an inverse proportion to that 
of the brain. 

It is not by this meant, that the excito-motory functions can never 
become unduly susceptible unless there be antecedent diminution of 
the voluntary ; nor that this excessive excitability may not exist as 
a primary affection, independently of disease elsewhere, but merely 
that it is most commonly observed in those states of the system when 
the voluntary power is the least; and further, that when the con- 
trolling influence of the latter is withdrawn, the former will be liable 
to be thrown into excessive action by ordinary causes of irritation ; 
and that when any such cause, of a more than ordinary character, 
comes into operation, we shall have violent spasm. Neither must 
we lose sight of the fact, that the nervous centres, the one as well as 
the other, have the power of originating muscular contraction, and 



470 SPASM — ITS NATURE. 

are liable to irritation from within, as well as from without, and con- 
sequently, that excessive contraction, or spasm of the voluntary 
muscles, may be excited by irritation, or hyperaemia of those centres 
or the parts proceeding from them, as well as by irritation along the 
course of those proceeding to them, and hence inflammatory disease 
of the brain, or of the spinal cord, may be simulated, as regards the 
u loesa partis functio" by irritation from without; that is to say, by 
peripheral and centripetal irritation, acting upon nervous matter, 
either in itself morbidly susceptible, or, as in the case of the spinal 
cord, uncontrolled by a power which is in a great measure antago- 
nistic to it: and thus similar symptoms may arise from opposite 
causes, and require opposite modes of treatment. If these principles 
are kept in view, they will guide us to the explanation of much that 
otherwise appears anomalous in the diagnosis and treatment of spas- 
modic diseases. 

In speaking of these affections, we shall proceed in the reverse 
order to that pursued by most authors, and commence with those 
which are most obviously the result of peripheral irritation. 

The most familiar instances occur in the convulsions arising from 
gastric irritation and teething in children. 

Now, as regards both of these, we have all the conditions which 
we have just pointed out as favouring abnormal excitement of the 
excito-motory system. We have the period of infancy, in which 
that system of nerves has the predominance over the voluntary, and 
we have an irritating cause at the extremities of one or other set of 
spinal nerves; but most children "cut" their teeth without convul- 
sions; and all do not go into fits every time that the milk "dis- 
agrees," or that they overload their stomachs ; accordingly we ordi- 
narily meet with these convulsions in children in whom, besides 
constitutional debility, generally of a strumous character, there is, in 
addition to a liability to gastric derangements from mesenteric dis- 
ease, a great susceptibility of the excito-motory system. If, from 
other causes, gastric irritation be set up, and there be more than 
ordinary inflammation of the gums in dentition, such children will 
be apt to be convulsed, and the greater the "nervous irritability," 
the greater the liability to be affected, even by the slightest irritating 
cause. In the diagnosis of these affections, we must carefully remem- 
ber the distinction which we have just pointed out between the oppo- 
site conditions which may produce the same results, namely, con- 
vulsions — and by close examination of the general state of the sys- 
tem, and inquiry into the previous history, satisfy ourselves that 
those symptoms which indicate inflammatory disease are absent; 
and, in the case of children in whom dentition is going on, we may 
pretty safely infer that the irritation proceeding from that process is 
the cause of the convulsions. In the case of gastric irritation, the 
irritable state of bowels, the generally abundant, or, at all events, 
not scanty urine, the fall pupil, and reddish tongue, the tumid abdo- 
men, the constantly quick pulse, and the absence of all the symptoms 
of inflammatory affections of the brain will point to the true nature 
of the case. 



CHOREA. 471 

The causes of these forms of infantile convulsion will best suggest 
the indications for their treatment. When the source of irritation is 
dentition, the gums should be freely lanced, and this having been 
done, we must proceed to allay the irritation elsewhere. When the 
heat of the skin is but moderate, and the other signs of general fever 
are wanting, we may put the child into a warm bath, of the tempera- 
ture of 100°; but if there be apprehensions of febrile excitement, 
the bath should not be used, except by immersing only the legs and 
thighs; the bowels must be carefully attended to, and if there have 
been merely frequent tenesmus and expulsion of mucus, with but little 
fecal matter, a drachm of castor-oil may be given, and subsequently 
the combination of two or three grains of bicarbonate of soda, with 
two or three of tincture of hyoscyamus will be found a most efficient 
sedative to the nervous system. When the convulsions continue to 
recur, we may have recourse to an injection of assafoetida; we must, 
however, carefully watch for any signs of cerebral excitement, as the 
irritation at the extremities of the nerves may, in children so predis- 
posed, set up inflammatory action in the encephalon. When this 
occurs, it must at its first appearance be properly met by the mea- 
sures already suggested. 

The same principles apply to convulsion arising from gastric irri- 
tation; the first object must be to remove all offending matters from 
the alimentary canal; for this purpose, from one to two grains of 
hydr. cum cret. according to the age of the child, may be given, and 
afterwards a teaspoonful of castor-oil; if, however, the bowels should 
have been extremely irritable, and the motions loose and abundant, 
it will be better to combine the hydr. cum cret. with three or four 
grains of compound chalk powder, and if there be much diarrhoea, 
from one to two grains of compound ipecacuanha powder may be 
added, and the castor-oil may be given guarded with a minim, or 
even two, of laudanum. The warm bath up to the hips may also be 
here used with advantage, and, if the convulsions recur, an enema 
of four or five ounces of solution of assafoetida may be administered, 
which often affords great relief. Cases are not very rarely met with, 
in which the laxative remedies above recommended have brought 
away a considerable quantity of scybake resembling sheep's dung, to 
the great benefit of the patient. The soda and hyoscyamus, or simi- 
lar soothing measures, may also be subsequently used with advan- 
tage, and followed by the course of treatment before recommended 
for children prone to mesenteric and other strumous diseases in the 
abdomen. 

Chorea. — Chorea Sancti Yiti, or, as it is popularly termed, St. 
Yitus's dance, is another spasmodic affection; the spasm being of a 
clonic character. It derives its name from the movements, some- 
times simulating those of the dancer at festivals or solemn games, 
and the name of St. Yitus has been added, as to the relics of that saint 
was ascribed the power of curing this affection. The appearance of 
a person suffering from this disagreeable affection is too well known 
to require minute description. The disease is most common in 
young persons of either sex, though perhaps young girls are more 



472 CHOREA — SYMPTOMS AND CAUSES. 

frequently affected than lads; it may, however, occur at almost any 
age. It is not very rare in children as young as six or seven; and 
there was once in Guy's Hospital a man of sixty who was the 
subject of chorea. 

The disease generally comes on gradually ; the child is observed 
to drop things, or to be unable to hold its book or thread its needle, 
or is seen to be twitching one hand, for which it is often reproved as 
for a bad habit. The movement, however, extends generally over 
the side where it is first observed, and that side of the body, includ- 
ing often the muscles of the face, is in a state of incessant motion, 
which movement sometimes assumes a character of regularity or 
almost gracefulness, as in the salaam convulsion. Generally, however, 
the movements are of an irregular and hurried character, most dis- 
agreeable to witness ; the voluntary control over the affected limbs 
being, in a great measure, superseded, so that when the patient 
is told to grasp anything, he makes several attempts with the hand, 
frequently missing it, and at last seizing it convulsively. The con- 
tinual movements of the muscles of the face give to the countenance 
an expression almost idiotic, aggravated, possibly, by the diminution 
of voluntary energy. The speech is also imperfect ; sometimes the 
power of articulation is entirely lost, the attempt to speak giving rise 
only to contortions of the mouth and tongue, attended with increased 
movements and an inarticulate sound. 

The disease does not, however, in all cases, come on thus gradu- 
ally, but it sometimes attacks a young person immediately after a 
sudden fright or powerful emotion. The convulsions also become 
sometimes so violent and uncontrollable that the patient cannot lie 
safely in an ordinary bed, and it becomes necessary to place him in 
a cot, or use some means of protection at the sides. The movements 
too, though almost always affecting one side, may extend to the 
other ; and if this be not the case, the muscles of the otherwise unaf- 
fected side are called into continual action to counteract those of the 
opposite side. 

Chorea, as must be apparent from what we have already stated, 
affects exclusively the muscles of voluntary motion, and those which, 
though not strictly such, are under the control of the will, as is the 
case with the muscles of respiration, the diaphragm being often 
implicated ; and a case occurred under my care, of a girl in Guy's 
Hospital, in whom there appeared to be chorea of the diaphragm 
alone. There is no proof of the purely involuntary muscles being 
implicated ; unless the curious fact, first pointed out by Br. Addison, 
of the frequent occurrence of a systolic " bruit de soufflef under the 
left nipple, be received as evidence of the muscular structure of the 
heart being affected ; the obscurity, however, of the mechanism of 
this so-called mitral " bruit" together with the frequent connection 
of chorea with rheumatism, go far to invalidate this testimony. It 
is remarkable, too, that the choreal movements are entirely sus- 
pended during sleep. 

The diagnosis of chorea is sufficiently obvious. 

The cause of chorea is generally some strong emotion, or other 



CAUSES AND TREATMENT. 473 

impression upon the nervous system ; in most cases fright is the 
active cause, in some a cut or blow, now and then depressing emo- 
tion. In a case which occurred lately, a boy of sixteen became the 
subject of chorea immediately upon hearing of the death of his father 
from cholera. The cause, however, which constitutes as it were, the 
essence of the disease, consists in an excessive susceptibility of the 
nerves of voluntary motion, so that the muscles are thrown into con- 
traction without the stimulus of volition, often in direct opposition 
to it, sometimes through stimuli conveyed from an extremity of an 
incident nerve ; sometimes it may be that the state of the nervous 
centre is such that muscular contractions are excited independently 
of any impression conveyed to it by the incident nerves. This state 
of the nervous system is in by far the greater number unconnected 
with any change in its substance appreciable by our senses, though 
it may sometimes be associated with structural change in the brain 
or spinal cord. We do, in fact, occasionally meet 6 with cases of 
chorea in which there have been chronic effusion into the ventricles 
or on the surface of the brain, often the result of strumous disease, or 
in which strumous deposits upon the pia mater have pressed upon 
the substance of the brain. In some of these, the choreal have been 
the first active symptoms of cerebral disease, and it is not improba- 
ble that the presence of such disease may have been the means of 
impairing the functions of the nervous substance. These cases, how- 
ever, are so rare as to prove that the cause must be sought for else- 
where ; and although we have no appreciable lesion in any part of 
the system, we have that condition which is commonly described as 
a want of tone ; the muscles are lax, the blood is often in an anaemic 
condition ; and undoubtedly, strumous boys and girls, and those 
living in large towns, are those who are commonly the subjects of 
chorea. 

The prognosis of this disease is generally favourable, though in 
those cases in which there are signs of sub-acute encephalitis, stru- 
mous meningitis, or of other diseases within the cranium, it must be 
in accordance with such symptoms. The treatment of chorea is in 
general simple and successful. The objects to be followed are — to 
obviate all causes of irritation or excitement, — to improve the gene- 
ral tone, and particularly that of the nervous system. 

When, therefore, the child or young person has been exposed to 
fright, or subject to irritation of any kind, all disturbing causes 
should be carefully guarded against, particularly the annoyance 
arising from evident imitation by other children. The bowels should 
be effectively cleared out, though irritation from purgatives should 
be avoided. With this view, the combination of calomel with scam- 
mony or jalap should be used every third or fourth night, and its 
action assisted, if necessary, with tartrate of potass and senna, or in 
delicate children the mixture alone may be employed. 

As regards tonics, we must be guided in our selection by the con- 
dition of the patient. Those which are in general most efficient are 
—the preparations of zinc and iron, the combination of port wine 
with rhubarb, and the shower bath. 



474 EPILEPSY. 

In ordinary cases the exhibition of purgatives to keep the bowels 
freely open, and the sulphate of zinc in doses gradually increased 
from a grain to twelve, fifteen, or twenty grains, or even more, will 
effect a cure. When, however, the sulphate has been used in these 
large doses, its sudden discontinuance seems to be felt by the system, 
and a return of the symptoms ensues : the best rule, therefore, for its 
exhibition is as follows : — the bowels being kept open, the sulphate 
of zinc should be given in doses commencing with a grain, and in 
the case of a child of about twelve years old the quantity should 
be increased by the addition of a grain to each dose daily until it 
either causes sickness or there is an obvious diminution of the cho- 
real movements. In the former case the dose should be diminished 
by at least one-half, and so continued for several days, with a view 
to establishing a tolerance ; but if, on the other hand, there be a 
marked improvement, it should be no further increased, but con- 
tinued without alteration until either the improvement ceases — in 
which case it should be again gradually increased — or the disease 
has altogether subsided. Whenever the latter is the case, we ought 
to diminish the dose day by day, rather than discontinue it suddenly, 
as by following the latter course we have less reason to dread a 
relapse. In some cases, however, especially those in which there is 
considerable anaemia, the iron seems to have more control over the 
disease than has the zinc, though these cases are rather exceptional 
ones. When such cases present themselves, and are apparent either 
from the anasmic condition above alluded to or from the failure of the 
zinc, we may administer either the ammonio-tartrate or the ammonio- 
citrate of iron in the usual doses, or the tinctura ferri comp. com- 
bined, when there is torpidity of the bowels, with the decoct, aloes 
co. (F. 89).* This form is particularly eligible for chorea occurring 
in connection with amenorrhoea. 

Epilepsy, or falling sickness — the morbus comitialis of the Latin 
authors — differs from chorea in that the spasm, though like it clonic, 
recurs only at intervals, that is to say, in fits or paroxysms, and in 
the important fact that the proper functions of the brain are sus- 
pended, there being loss of consciousness. An attack of epilepsy is 
generally sudden in its invasion ; the patient may have been but the 
instant before to all appearance in perfect health, when he suddenly 
utters a most terrific cry, and falls senseless and convulsed ; he then, 
in the words of Dr. Watson, "strains and struggles violently — his 
breathing is embarrassed or suspended — his face turgid and livid — 
he foams at the mouth — a choking sound is heard in the wind-pipe 
— he appears to be at the point of death by apncea. But presently 
and by degrees these alarming phenomena diminish, and at length • 
cease ; the patient is left exhausted and comatose, but his life 
is no longer threatened, and in a short time he is to all appearance 
perfectly well. The same train of morbid phenomena recur, how- 
ever, again and again, at different and mostly at irregular intervals." 

* (89) R. Tinct. Ferri co. 3 v. 

Decoct. Aloes co. g irj. 
Ft. Haust. ; to be taken three times a-day. 



PATHOLOGY. 475 

The epileptic attack or fit in many cases comes on suddenly, as we 
have just observed, and without the slightest warning. But it is not 
very uncommon, on the other hand, for patients to have some pre- 
monitory symptom, with which they often become familiar, so as to 
become aware of the approach of the fit. In some instances there is 
vertigo, or confusion of intellect; sometimes there is unusual irrita- 
bility of temper, which may exist for several days previous to the 
fit ; and in some cases there is an inordinate appetite for food — that 
not uncommon symptom of cerebral disturbance. Sometimes, again, 
there are symptoms recognisable by the attendants or friends of the 
patient, as imperfect articulation, slight distortion of the face, or 
squinting. But the most remarkable of the premonitory signs is the 
well known "aura epileptica," which consists of a feeling as of the 
passage of a current of air from some part of the body, generally one 
of the extremities, to the head, or sometimes to the pit of the sto- 
mach, and which is immediately followed by an epileptic fit. 

The true pathology of epilepsy is very obscure. If we look to 
the symptoms we find them to consist principally of a suspension 
of the proper functions of the brain — sensation, volition, con- 
sciousness — with violent clonic spasm; the muscles of respiration 
being always implicated, and the sphincters paralysed; the urine 
being generally voided during the fit, and the lower bowels being 
commonly emptied. It is not, however, so obvious whether these 
spasms arise from derangement in the brain itself, or in the true 
spinal or excito-motory system; the fact of the natural functions of 
the brain being suspended does not preclude the possibility of the 
motor fibres exciting abnormal or violent muscular action, the more 
so since we know that disease or injury of the brain will sometimes 
produce convulsions at the same time that it takes away the con- 
sciousness. There is also reason to believe that disease of the spinal 
cord, or its membranes, is more apt to produce tonic spasm than con- 
vulsion; at the same time, we know that irritation in the course of 
the nerves will produce spasm, and that too of a clonic character; 
and from the analogy of other diseases, we should expect these move- 
ments to be the more violent and irregular when the controlling 
power of the sensorium is withdrawn and in abeyance; and, there- 
fore, it is not impossible that disease or irritation of a portion of the 
nervous matter constituting the cord may excite the spasms, and that 
they are more easily excited where the proper functions of the brain, 
as regards volition and consciousness, are impaired. It is to be borne 
in mind, too, that the spinal cord has a double function — one as an 
independent organ, and the other as a part or appendage of the 
brain ; and, therefore, we may well believe that as regards the motor 
columns, or those proceeding from the brain, irritation in any part 
of their course might act as stimulants to the muscles to which they 
are distributed, and excite them to contraction ; and the same thing* 
may be true of the white matter itself; we therefore perceive that it 
is possible that it may be excited in any part of the nerves proceed- 
ing from the brain, as well as of the brain itself; but we also know 
that irritation at the extremities of the incident nerves, or along their 



476 EPILEPSY. 

course, will produce irritation of the brain itself, and therefore we are 
driven to the conclusion that epilepsy may have its origin in any part 
of the cerebro-spinal sj^stem. 

Morbid anatomy, again, does not throw any certain light upon 
either the nature or the seat of the lesion, upon which epilepsy 
depends : it is true that in the bodies of those who have died in epi- 
leptic fits, and in whom there had been no other symptoms referable 
to the brain, congestion of the vessels in the substance and on the 
surface of the brain is generally found ; but this congestion is in all 
probability the result of the mode of death, namely, apnoea. Others, 
again, have had repeated attacks of epilepsy, and who, as commonly, 
happens, have evinced some signs of diminution of the functions of 
the brain — as impaired intellect, or paralysis, or diminished muscular 
power, and have been inspected after death, which has occurred inde- 
pendently of an epileptic fit ; and in some of them there have been 
found induration and dilatation of the blood-vessels, in others soften- 
ing with a similar dilatation ; these changes affecting the white matter; 
whilst the gray matter is sometimes altered in consistence, easily re- 
moved from the white matter, and adherent to the membranes; but 
these are precisely the changes observed in those who have had 
similar affections independently of epilepsy; and where the other 
symptoms of celebral disease have supervened, as they often do, upon 
repeated attacks of epilepsy, it is more reasonable to attribute the 
changes in the brain to the excitement and disturbed circulation 
attending the fits, than to suppose that the fits have been produced 
by what appears from the symptoms to have been a subsequent 
lesion. 

On the other hand, we sometimes find evidence of sources of irri- 
tation which must have been permanent, and in some instances con- 
genital, as thickening of the membrane, tubercles on the surface, 
spiculse of bone, or other alteration of the bones of the cranium. 
These no doubt may be what are termed "predisposing causes," or 
rather conditions increasing the liability to epilepsy. 

There have been various classifications of epilepsy, but we agree 
with Dr. "Watson in regarding that which divides epilepsy into excen- 
tric, or proceeding from irritation external to the nervous centres, 
and centric, or induced by irritation within them, as the one most in 
accordance with our knowledge of the pathology of the disease ; or if 
we might express the same idea in somewhat different language — 
epilepsy may be centripetal, that is to say, excited by irritation at 
the extremities of the incident nerves, and proceeding through the 
cerebro-spinal axis, exciting convulsion by the reflected nerves ; or 
proceeding direct from the nervous centre, the irritating cause being 
in that situation. 

The conditions which predispose to epilepsy are, a peculiar con- 
formation of the head ; conical, sometimes flattened, more commonly 
unsymmetrical as regards the two sides, or affected with chronic 
hydrocephalus. Scrofula also produces great liability to this disease, 
and it is no uncommon thing to meet with epilepsy in persons who 
have plain marks of scrofula upon them, or in a member of a family 



DIAGNOSIS — PROGNOSIS — TREATMENT. 477 

of which, others are obviously scrofulous. Like scrofula, too, epilepsy 
is often hereditary. Intemperance and excesses of all kinds also 
favour if they do not absolutely induce a liability to epilepsy, and of 
this class of causes of debility there is none more frequent or more 
effectual than the wretched habit of self-abuse. 

The essential causes of epilepsy are, we have said, involved in 
obscurity, but some occurrences certainly appear, in those who are 
susceptible, to act as causes. Amongst these we may enumerate 
strong mental emotion, particularly fright, repressed eruptions, par- 
ticularly about the head; and so will suppressed discharges, and, 
what may at first sight appear extraordinary, haemorrhage will 
also produce the same result. The sight of another person in an 
epileptic fit has been known to produce the disease in a person wit- 
nessing it, and a patient who has had previous fits is very likely to 
be thrown into one by witnessing such a spectacle ; and so likely is 
it to be induced by imitation that those who have feigned to be epi- 
leptic have been known eventually to become really so. 

The diagnosis of epilepsy is, in the majority of cases, not difficult; 
but there are three conditions from which it is important to distin- 
guish it — from apoplexy, from hysteria, and from no disease at all, 
that is to say, from malingering or feigning. 

In a case where the previous history is known, or where we have 
been made acquainted with the circumstances of the attack, there is 
no great difficulty in distinguishing epilepsy from apoplexy ; but if 
we are called to a person who has been found in a fit some caution 
is required in this respect. In the first place, it must be borne in 
mind that epilepsy may be apoplectic; that is to say, that the injury 
to the brain which produced apoplexy may, at the same time, pro- 
duce epilepsy ; in this case, there will be the signs of apoplexy super- 
added to those of epilepsy. The pulse will be either full and labour- 
ing or quick and feeble ; the breathing will be slow and stertorous, 
not hurried and gasping and whistling, as in ordinary epilepsy; and 
in such cases it will generally happen that the convulsion is hemi- 
plegic; that is to say, affecting one side almost entirely. It must be 
remembered, too, that epilepsy is far more frequent in early life than 
is apoplexy. 

Hysteria may still more closely simulate epilepsy, and in some 
instances, perhaps, hysteria does give rise to true epilepsy; that is to 
say, the seat of irritation may be in the uterus or its appendages. In 
most cases however of hysteria, which simulate epilepsy, we may 
observe that the patient has sufficient consciousness not to injure her- 
self in her convulsions ; she does not bite her tongue or bruise herself, 
and there is frequent screaming, whereas, although epilepsy begins 
with a cry, it is not repeated. 

The greatest difficulty, however, is with malingerers, if they are skil- 
ful ones. Here we have none of the differences pointed out in the 
last case. Pretenders rarely hurt themselves by their falls, though 
they may have resolution to bite the tongue. They generally, too, 
choose public situations or places, which will serve to attract the 
attention of those whom they wish to deceive, for their performances, 



478 EPILEPSY. 

but will rarely exhibit before a medical man. Their contortions are 
often more violent than those of real epileptics, and the more so the 
more they are watched ; but though more violent the convulsions are 
not so forcible ; the true epileptic exhibits a power during the fit far 
beyond what is natural. Epileptics during the fit are insensible to 
external impressions, and the pupils are not obedient to the stimulus 
of light, circumstances, the latter especially, which it is impossible to 
simulate. In epilepsy, again, the eyelids are partially open, and the 
eyeballs prominent and distorted, whereas the malingerer generally 
closes his eyes altogether. Various contrivances have been suggested 
for detecting impostors of this kind. A very ingenious one is that 
proposed by Dr. Watson, of expressing an intention in the patient's 
hearing of pouring boiling water upon him, and then proceeding to 
pour cold. 

The prognosis of epilepsy is in the general way unfavourable ; it 
is less so before puberty than after, in females than in males. The 
changes which take place in the nervous and circulatory systems 
about the time of puberty may be hoped to be beneficial in those 
who have been thus afflicted, and particularly so in females; and 
even after puberty has been established, uterine, derangements are 
so frequently a source of fits, which though they might perhaps be 
called hysterical are so perfectly epileptic in their character, that 
we cannot regard them as anything else, unless we are guided solely 
by a suspicion as to their origin ; and as this must always be obscure, 
we may reasonably hope that in such subjects the disease is de- 
pendent upon a cause which is not necessarily permanent. 

As regards the form of disease itself, the centric is necessarily more 
incurable than the excentric, and the excentric is more hopeful in the 
inverse proportion of the time during which it has lasted. 

The treatment of epilepsy during the fit must be directed to pre- 
venting the patient injuring himself, and obviating any immediate 
danger from the violence of the convulsion, the impediment to the 
respiration, and the disturbance of the circulation. For the former 
purpose it is necessary to place the patient in such a position as that 
he shall be least liable to strike himself against anything that will 
hurt him during the paroxysm ; and if possible to thrust a piece of 
cork, or part of a silk handkerchief between the teeth. Great watch- 
fulness should also be exercised over those who are liable to epilepsy, 
to prevent their placing themselves in a position in which a loss of 
power of supporting themselves would be peculiarly dangerous ; as 
before a fire, by the water-side, or unattended in a great thoroughfare. 

The next object is to guard against any internal injury. Now it 
may be apprehended that epilepsy, -from the obvious engorgement 
of the vessels of the head, may give rise to apoplexy, and that to 
prevent such a catastrophe it would be well to bleed the patient 
from the arm ; but experience has shown that this measure is a 
dangerous one ; whether it be that you cannot greatly relieve the 
internal pressure in this way, whilst there is so much obstruction to 
the circulation owing to the suspended respiration, or whether it be 
that the effect of the abstraction of blood is to prolong the fit, and 



TREATMENT. 479 

aggravate its violence, the result of bleeding during an epileptic fit, 
provided it be really such and not apoplectic, is that several persons 
so treated have died ; whereas death from an epileptic fit is a compara- 
tively rare occurrence ; and further than this the tendency to a re- 
currence of the fits is much increased by the depressing effects of blood- 
letting upon the system at large. But though this may not be done, 
we may apply cold to the head, and when the fit is long continued, 
and particularly if there be reason to believe that the bowels have 
not been freely relieved during the preceding twenty -four hours, a 
stimulating clyster may be administered. The treatment between 
the fits is the most important, and must be directed towards removing 
the proclivity to the fits, and protecting the patient from their more 
obvious causes. 

In the first place, all those circumstances which tend to increase 
the liability should, if possible, be removed. We cannot indeed 
relieve the patient of his inherited liability to this dreadful malady, 
neither can we cure him of those habits, generally evil in themselves, 
which aggravate, and in some cases even originate the liability ; but 
we can warn him of their evil consequences, and point out the certain 
ruin to which he is hurrying himself. It is true, indeed, that our 
warnings will but too often be, like those of the teachers of morality 
and religion, listened to with attention, and their reasonableness 
acquiesced in, but disregarded or forgotten upon the first temptation ; 
but whilst we find some who are increasing their susceptibility to 
epilepsy by vicious courses, we meet with others who are bringing 
about the same result by pursuits harmless, or even praiseworthy in 
themselves ; and they also must be warned that what others may do 
with impunity they must not attempt, except at the peril of increased 
frequency or severity in the attacks. To use the graceful language 
of Dr. Watson, " The patient who is subject to epilepsy should live 
by rule, and be temperate in all things. His diet should be simple, 
nutritious, but not stimulating. He should renounce all strong 
liquor, and become, in the new-fangled and vulgar phrase, a tee- 
totaller. He should rise early and take regular exercise in the open 
air; keeping his head cool, and his extremities warm. He should 
avoid all mental excitement, and the fatiguing pursuit of what is 
called pleasure ; all probable sources of sudden anger, surprise, alarm, 
or deep emotion of any kind; all striving and contention of the 
intellect. The student of whatever age and sort in whom epilepsy 
has declared itself, should shut his books ; the man of business 
abandon or abridge his professional toil ; at least they must be in- 
structed to abstain habitually, in their respective callings, from such 
application as would task and strain their powers, whether mental or 
bodily; and endeavours should be made to engage their thoughts, 
and interest their minds in less engrossing objects of attention." 

As regards more active measures, it is most important to keep up 
all the evacuations in their natural activity, or rather beyond it : and 
sometimes it may be well to set up some artificial discharge, especi- 
ally if the disease have supervened upon the suppression of any, 
whether natural, morbid, or artificial ; but in doing this the general 



480 EPILEPSY. 

health must be maintained at its full standard, and the tone of the 
system improved as far as can be without inducing plethora, or 
excitement. It is therefore necessary to have recourse to occasional 
purgatives to insure a free action of the bowels ; and where there 
has been suppression or diminution of any previous discharge, as 
from haemorrhoids, or former ulcers, a blister should be applied, from 
time to time, at the nape of the neck ; and when the former discharge 
has been of long continuance a seton should be used. In females in 
whom there has been a cessation or diminution of the catamenia, 
aloetic purgatives should be employed, and where there is any ap- 
pearance of anaemia they may be combined with iron. The mist, 
ferri co. with decoct, aloes co. answers this purpose admirably. 

When there is decided evidence of a plethoric condition, and the 
pulse is strong and hard, and previous attacks have been preceded 
by head-ache, with throbbing of the carotid and temporal arteries, 
with evident congestion of the superficial veins, blood may be ab- 
stracted with benefit ; but even this will, in the majority of cases, be 
best done by cupping from the nape of the neck ; when these symp- 
toms are wanting we shall best obviate the tendency to local hyper- 
aemia by the use of tonics. Amongst these we must not omit those 
most important ones, air and water. Moderate exercise in the open 
country, where it can be effected, should always be employed, and 
the cold shower-bath, which may always be safely employed if it be 
followed by a gentle glow upon the surface. Of tonics the mineral 
ones seem to have the greatest control over the fits. Iron is not 
admissible when there is much head-ache, or when that symptom 
follows its use: copper is perhaps next to iron as a general tonic, 
and has perhaps more influence upon the nervous system. It may 
be given in the form of sulphate, in doses beginning at a fourth of a 
grain, and gradually increased to three or four grains, provided it 
produce no irritation in the stomach or bowels ; it has frequently 
greatly prolonged the intervals between the fits, though in two in- 
stances in which it was employed, the fits when they recurred did so 
with greater, and in one instance, fatal violence. Silver, in the form 
of nitrate or oxide, has been much praised as a remedy for epilepsy, 
and in the cases requiring tonics it is one of the best ; it has however 
the disadvantage of sometimes rendering the skin black, or rather 
bluish, by the deposition, as it is supposed, of the oxide of the metal 
upon the rete-mucosum ; certain however it is, that such an event 
has sometimes followed its use. Zinc is not liable to the same objec- 
tion, and from its superior efficacy as a nervine tonic, and its being 
less apt to cause determination to the head than any other of the 
mineral tonics, is upon the whole the most eligible. It may be given, 
as in chorea, in doses gradually increased from one grain to twenty 
or more, as far as the stomach will bear it ; and when it has pro- 
duced a decided benefit, the dose should be reduced upon the de- 
scending scale. 



ASTHMA — ITS PATHOLOGY. 481 



ASTHMA. 

In speaking of the diseases of the air-tubes and lungs, we have 
alluded to the paroxysms of dyspnoea which are often familiarly 
known by the name of asthma ; but besides these there is the true 
asthma, with which little or no anatomical change is associated, and 
is probably of purely nervine or spasmodic character. An attack of 
asthma is generally preceded by signs of disorder of the digestive 
functions ; there are flatulent distensions, headache, lassitude, depres- 
sion of spirits. Towards evening there may be weight and oppres- 
sion across the chest, with some difficulty of breathing, and perhaps 
in this state the patient retires to rest. The urgent dyspnoea gene- 
rally comes on after midnight, generally about two or three o'clock 
in the morning, when the patient awakes with a feeling of constric- 
tion across his chest, and an inability to draw in his breath. He 
is compelled to rise, and sits bending forwards, with knees drawn 
up, labouring for breath, and often wheezing loudly, and complain- 
ing of a feeling of impending suffocation; he expresses an urgent 
desire for fresh air, and will go and open the window to get breath; 
and, what is characteristic, he rarely experiences any ill effects from 
so doing. The face is often livid from congestion, at other times pale 
and shrunken. There is generally much palpitation of the heart, 
with a feeble, and sometimes intermittent pulse, indicative of 
obstructed pulmonic circulation. If there be any urine voided, 
which there not uncommonly is at the commencement of a par- 
oxysm, it is copious, pale, and limpid, like that of an hysterical 
female. The bowels, too, are often relaxed, with a spasmodic action. 

The fit lasts for several hours, and generally subsides towards 
morning, when the dyspnoea begins gradually to subside, the patient 
is enabled to breathe, speak, and cough with ease, and at last sinks 
into a quiet sleep. This is often preceded by a copious, thin, frothy 
expectoration. When this occurs the patient is said to have humid 
asthma, but sometimes there is none, when the case is said to be one 
of dry asthma. These paroxysms will sometimes recur for several 
nights in succession, the patient often saying in the intervals that he 
feels quite well, though there is generally apparent more or less 
difficulty in speaking. 

There are no anatomical changes found which account for this 
disease; there may be emphysema of the cells of the lungs, and 
enlargement of the right side of the heart is not uncommon; both 
these, however, are often found without asthma; and though the 
former, when extensive, always gives rise to more or less dyspnoea, it 
is of a constant, rather than a paroxysmal character, and the latter is 
more probably an effect than a cause. 

The absence of all structural lesion in the chest, as well as the 
general spasmodic nature of the attack, the almost hysterical symp- 
toms, and the pale, limpid urine, all tend to show that asthma is a 

31 



432 colic. 

nervine affection, probably of a spasmodic character, the seat of the 
spasm being in the muscles that encircle the air-tubes. 

The circumstances which excite the paroxysms show that the 
spasm may have a centric or excentric origin, originating, in the 
former case, in the nervine centres, thus mental emotion will often 
bring on an attack; and as instances of the latter, we may adduce 
gastric irritation, the pneumo-gastric being in this case the incident 
nerve which conveys the impression to the centre. It is not there- 
fore surprising that bronchial irritation should be another cause, and 
that whatever produces a strong impression upon the bronchial 
membrane should induce an attack: thus, changes in temperature, 
or in the humidity of the atmosphere, will often bring one on; 
though different asthmatic subjects are variously affected in this 
way, an unusual degree of moisture bringing one on in some, whilst 
others rest best in low, damp situations. The susceptibility to 
asthma often arises from hereditary predisposition; it appears also 
to be induced by a lax habit of sj'stem, by gout, and by long-con- 
tinued dyspepsia. 

From the dyspnoea of emphysematous lung, or dilated tubes, as 
well as from that from disease of the heart and large arteries, 
asthma may be distinguished by the absence of the physical signs of 
those diseases, and by the paroxysms generally coming on at night. 

The prognosis of asthma is in early attacks favourable; but a 
frequent repetition of them may exhaust the strength of the patient, 
and induce emphysema of the lungs, enlargement of the right heart, 
obstruction of the pulmonic circulation, and death from apnoea. 

During an attack of asthma, if there be signs of great congestion 
about the head, a few ounces of blood may be taken by cupping 
between the shoulder-blades; but as a general rule the abstraction of 
blood is to be avoided. A combination of the compound sulphuric- 
aether, or chloric sether, with opium (F. 90),* gives much relief during 
the paroxysms; and a most efficient measure is the smoking of the 
leaves of strammonium, commonly known as herb-tobacco. 

In the intervals, every means should be used to improve the 
general health and the tone of the system ; and that locality should 
be selected where the patient can breathe most freely. A course of 
sulphate of zinc, carried to the extent of about four grains three or 
four times a-day, should also be had recourse to. 



COLIC. 

Colic is a disease which, as regards the bowels, is in many respects 
analogous to asthma, as regards the lungs. Like the former, it pre- 
sents several of the symptoms of disordered function induced by 
inflammation, but it is not inflammatory in itself, and is unconnected 

* (90) R. Sp. Mth. co. ttl xx. yel JEtheris Chlorici, n^ xv. 
Tinct. Opii, rr^ xv. 
Mist Caniphorge, ^ j. Misce. 
Ft. Haust. ; to be taken during the paroxysm. 



a 



ITS PATHOLOGY. 48{ 

with inflammation, unless the latter occur as an effect, or as an acci- 
dental complication. 

The symptoms of colic are, severe twisting pains in the abdomen, 
referred particularly to the umbilicus, the bowels being obstinately 
confined ; there is generally considerable flatulence, and often nausea. 
The pain is relieved by pressure, and the patient may often be seen 
to press his hands upon the abdomen for that purpose; the pulse 
and tongue are unaffected. The symptoms will often subside upon 
a free evacuation of the bowels, but if that do not occur, the pains 
will be more severe and constant, the abdomen tender, and the case 
will pass into one of obstructed bowel, or of ileus or enteritis. 

As in the case of asthma, there are no anatomical changes con- 
nected with colic as such, the colon is found firmly contracted in one 
part, and largely distended in that immediately above or tergal to 
it; this appearance is commonly explained upon the hypothesis of 
spasm of the former part, and paralysis of the latter; and in ordinary 
cases this is probably the most satisfactory explanation, though it 
must be recollected, that if there be sudden stoppage of the bowels 
from any other cause, and the same may be true of paralysis, there 
will be contraction beyond it. 

The causes of simple colic are, cold applied to the surface, more 
particularly the abdomen and lower extremities, accumulations of 
hardened matters, hysteria, spinal disease. It is in fact a nervine 
affection, in which the paralysis or irritation may originate from the 
spinal cord or the brain; or it may be excited by an impression 
upon the incident nerves, as in case of cold to the surface, or irri- 
tating substances in the bowels itself. 

There is, however, one form of colic the history and symptoms of 
which clearly indicate its nervine origin, and that is Colica Pictonum, 
familiarly known as painters 1 colic, or Devonshire colic, or dry belly- 
ache of the West Indies, and in all cases it has been traced to the gra- 
dual introduction of lead into the system. In Devonshire it has often 
arisen from the use of cider, the common drink of the country people, 
which had been prepared in machinery in the joints of the several 
parts of which lead had been employed, the acetic and malic acids of 
the apples having formed soluble salts with that metal. 

This disease commences with the same symptoms as the ordinary 
colic, but it does not end with them. It may be just after one of 
these attacks, or it may be during a second or a third, that one hand 
or both of them drop, as the workers in lead term it, so familiar are 
they with the fearful malady. About the same time with these 
symptoms another and very remarkable one presents itself, for the 
acquaintance with which the profession is indebted to the late Dr. 
Burton of St. Thomas's Hospital. This is a bluish or purplish line 
along the edges of the gums. The immediate cause of the phenome- 
non is the deposition of sulphuret of lead, the sulphur being probably 
furnished by animal matters admitted into the "tartar" that forms 
on the teeth, or the sulpho-cyanic acid in the saliva; the lead is 
from the salt of that metal which has entered the circulation. 

The palsy is the first amongst the nervine symptoms, but it is not 



484 COLICA PICTONUM. 

the only one. Sometimes there are at the commencement pains in 
the head and sometimes cramps. In severe cases, generally those in 
which there has been several attacks of the colic, the paralysis extends 
to the lower extremities, and the sufferers become miserable cripples. 
Frequently there are at the same time pains in the limbs, often called 
rheumatic, but which close inquiry into the history of the case, aided 
by inspection of the gums, show to be lead-poisoning. The paralysed 
muscles waste, and the patient loses colour in the face and lips, one 
effect of lead being apparently that of diminishing the quantity of 
red corpuscles, and he either dies of general paralysis or is carried 
off by some visceral disease. 

The diagnosis of colic is not difficult. As long as it is only colic 
it may be distinguished from the other diseases of which we have 
spoken as interrupting the functions of the bowels by the absence of 
their characteristic symptoms; when these present themselves it 
ceases to be colic. 

The prognosis of a first attack of colic is favourable ; recurrences 
of lead colic will sooner or later terminate as just described. 

Ordinary colic is best treated by calomel and opium, in doses of 
about a grain each, repeated every three hours for three times ; after 
which half an ounce of castor oil may be given and an enema of soap 
and water administered, or the patient may be put into a warm bath, 
and about a quart of the water thrown up into the bowels. If, how- 
ever, there be evident indication of inflammatory action, blood may 
be taken from the arm. This, however, is a measure not to be wan- 
tonly practised in lead colic, since the abstraction of blood favours 
its absorption into the sj^stem, and promotes the anasmic character 
which is one of the effects of the poison. 

The treatment of the paralysis is far more difficult. The best plan 
is to put the dropped hand on a splint ; a blister may be applied to 
the arm, and on the excoriated surface there may be sprinkled about 
one-eighth of a grain of strychnine well mixed with ten grains of 
tragacanth powder. 

To eliminate the poison from the system various means have been 
suggested. Mercury has been recommended, but is worse than use 
less. Nitric acid has appeared to be beneficial, and of late the 
iodide of potassium has been used with much benefit. 



INTERMITTENT AND CONTINUED FEVERS. 485 



XXVII. 
INTEBMITTENT AND CONTINUED FEYEES. 

When a person has been attacked with chilliness, or shivering, or 
lassitude, and this has been followed by increased heat of skin, acce- 
lerated pnlse, pains in the limbs, coated tongue, loss of appetite, 
thirst, and general derangement of the functions of the system, he is 
said to be the subject of fever. 

This state, as we have seen, may be excited by inflammation exist- 
ing in any part of the system, and is then termed inflammatory fever ; 
but, on the other hand, it may arise as a primary disease, independ- 
ently of any local affection, and is on that account called idiopathic 
fever. We have already seen, in treating of inflammation, that the 
character of the fever admits of considerable variations, sometimes 
marked by continued force and frequency of the pulse, evincing the 
truly inflammatory fever, and at others characterised by softer pulse, 
greater tendency to prostration, and failure of the moving powers of 
the circulation, constituting what has been termed typhus* fever : and 
it will generally be found that these idiopathic fevers are more or 
less of the latter character. 

It is not altogether to be overlooked that many distinguished phy- 
sicians, more especially on the continent, have maintained that all 
fevers have their origin in some local inflammation, and in proof of 
this, there has been adduced the almost constant occurrence of some 
change which might be ascribed to inflammation in the bodies of 
those who have died from them. If, however, this evidence be care- 
fully analysed, it will become apparent that there is no lesion, essen- 
tially characteristic of fever, which may not be explained by the 
congestion, arising from the impeded circulation in the extreme 
vessels, dependent, probably, upon an altered condition of the blood ; 
or which may not be shown to be the result of an inflammation aris- 
ing in the progress of the fever ; and consequently, if at all con- 
nected with the fever, in the way of causation, so connected as effect 
rather than as cause. 

Setting aside, then, the theory that ascribes all fevers to the effect 
of a local inflammation ; both for the above reasons, and also upon 
the ground that nearly all physicians have found the practical neces- 
sity of recognising the existence of a state of pyrexia, that may be dis- 
tinguished, by its history and symptoms, from fever arising from a 
local inflammation, we proceed to state briefly the signs by which 
idiopathic fever in general may be distinguished. 

First of all we have the negative sign, that of the absence of all 
symptoms which indicate the existence of inflammation in any part ; 

* By typhus we mean typhus, and by typhoid we mean typhoid, or fever resembling 
typhus. 



486 CHARACTERS OF FEVER. 

and to this may be added the character of the fever, that it is 
always prone to the typhoid or sinking form ; thus the pulse is more 
readily compressed than in the inflammatory fever : the secretions 
generally are more vitiated, especially those about the mouth, which 
speedily become viscid and dark. The nervous system is generally 
more oppressed, there being early stupor or confusion, great weak- 
ness, with giddiness or vertigo, and a tendency to syncope on the 
slightest attempt at exertion. There are derangement of the exter- 
nal senses,— generally in the way of diminution, — as shown by the 
frequent tendency to deafness ; a failure rather than perversion of the 
intellectual faculties, as shown by the character of delirium, unat- 
tended with violence, generally approaching to stupor, and commonly 
described as low and muttering. There is an altered condition of 
the blood, which shows impaired vitality, sometimes losing entirely 
its power of coagulation, and at others showing signs of putrescency, 
giving rise to gangrene from slight irritation, — the red corpuscles, 
too, often breaking and allowing the effusion of the colouring matter 
through the serum or into the tissues, whence arise petechias, vibices, 
and passive haemorrhages. 

Over and above these symptoms of depression of the nervous 
power, and so-called putrescence of the blood and tissues, there is 
often a disposition to a defined inflammation of the skin, in many 
instances of a specific character, and appearing a certain time after 
the first invasion of the fever ; this belongs essentially to what are 
termed the exanthems or eruptive fevers, but is seldom altogether 
wanting in the ordinary continued fever. 

Another remarkable peculiarity by which idiopathic fever is dis- 
tinguished from that which attends local inflammation, is its tendency 
to spontaneous favourable termination. This tendency shows itself 
in a variety of ways, which forms, in fact, the basis of the division of 
fevers into three pretty generally recognised classes. 

In the first or intermitting form we have a perfect subsidence of the 
febrile symptoms after a cold and hot stage ; this subsidence being 
attended by a copious spontaneous sweating, the fever returning 
after an interval of twenty-four, forty-eight, or seventy-two hours, 
and again subsiding, after running through the same course. 

In the second or remitting form of fever, there are distinct remis- 
sions of the symptoms, occurring generally once in twenty-four 
hours, but not perfect subsidence of them. 

The continued fever, in which there is little or no abatement of the 
symptoms for several days, when sometimes as early as the seventh 
and at others as late as the thirtieth, or even fortieth, but most com 
monly about the twentieth day, or even earlier, a spontaneous subsi- 
dence of the symptoms takes place, sometimes very gradually, and 
at others almost suddenly, and attended by copious evacuations 
from the skin or kidneys. 

Another remarkable circumstance, and one peculiar to idiopathic 
fever, as opposed to that arising from local inflammation, is its ten- 
dency to become epidemic in districts or communities : thus showing 
that it arises not from general causes, like those which excite com- 



DIFFERENT FORMS OF FEVER. 487 

mon inflammation, but is the effect of some agencies which have a 
local or temporary operation. Of the local and temporary, we have 
good evidence of the existence of two, one or the other of which, or 
both conjoined, are the immediate causes of all idiopathic fevers ; 
namely, malaria or contagion. 

Of the existence of one form of malaria ; namely, that proceeding 
from the decomposition of vegetable matter, commonly known as 
the marsh miasm, there is little or no doubt, either in the minds of 
medical men or of the public generally; and this miasm is also 
acknowledged to be the alone cause of intermittent fevers or agues. 
This poison may possibly be generated accidentally, so. as to effect 
only a particular individual or family ; or from causes to be pre- 
sently noticed, its effects may not manifest themselves in an indivi- 
dual till after he has been for sometime removed from the sphere of 
its influence ; but they are so commonly observed to prevail in 
marshy countries, that there is no doubt entertained of these effects 
being produced by a local cause, and the disease is said to be endemic 
(p. 22). • Now these endemic intermittent fevers are never communi- 
cated by personal intercourse to persons living beyond the district 
in which they prevail, and are also observed so constantly in marshy 
localities that there has been no controversy as to the origin of the 
morbific agency. 

Other forms of fever, are observed to prevail for a time in a com- 
munity, attacking large numbers in quick succession, and then 
subsiding, often reappearing in some neighbouring population, and 
in this manner sometimes traversing whole continents ; these are said 
to be epidemic (p. 22). Concerning the origin of such diseases, there 
is much more doubt than in the case of the endemic. Some of them, 
of which the best instances are amongst the eruptive fevers, are so 
undoubtedly propagated by intercourse with subjects of the disease, 
that no doubt has ever been entertained by the experienced of the 
existence of contagion; but even with these there are obviously other 
conditions which regulate their extension through a population; so 
that although the existence of contagion as an immediate cause can- 
not be called in question, the agency of some other condition, in 
order that that cause may take effect, is hardly to be disproved. 
Other epidemics again attack a population so suddenly as scarcely to 
admit the supposition of their being propagated mainly by human 
intercourse, and thus we are constrained to recognise the possible 
existence of a malaria not depending upon local causes, but coming 
suddenly upon different districts. The question, then, of the origin 
of epidemic diseases becomes a much more complicated one than that 
of the endemic. 

The stating a disease to be contagious implies also that it arises 
from an animal poison; since it means that a person affected with a 
given disease is capable of generating in his own person a poison 
similar to that which first excited the disease in himself, and which 
is therefore capable under favourable circumstances of exciting a 
similar disease in another; and herein consists the difference between 



488 INTERMITTENT FEVER. 

such, poison and poisons derived from the mineral and vegetable 
kingdoms. 

Setting aside, then, for the present the eruptive fevers, we may lay 
it down that there are some arising from the marsh miasm, and 
which are not communicated from person to person, but are endemic 
in certain localities ; these are of the intermittent form ; that there are 
others which are apt to affect a population for a time, the spread of 
which is favoured by filth and the presence of decomposing animal 
matter and which are also rapidly propagated when a number of per- 
sons affected with them are crowded together, so as to leave no doubt 
that the specific poison exciting the disease may be generated or mul- 
tiplied within the system; and these fevers are of the continued form. 

Enough has perhaps been already stated to make it apparent that 
the doctrine which would ascribe all fevers to the effect of a local 
inflammation is not founded on a comprehensive view of the facts, 
and the same may be said of that which would explain them solely 
upon the principle of a change in the blood, or disturbance of the 
nervous system. We shall be nearer the truth in stating — what 
indeed is not so much the enunciation of a theory as a summary of 
the facts observed in the progress of various forms of fever — that the 
morbific agent, after remaining for some time latent in the system, 
acts simultaneously upon the blood and its moving powers — upon 
the heart and upon the extreme circulation, i. e. upon the vital inter- 
action of the blood in the capillaries and the tissues, — upon the 
nervous system, and upon the functions of the secreting organs, — 
unless indeed these latter actions are to be included in the two former. 

But the peculiar action of the morbific cause upon all these parts 
of the system is a depressing one, and this depression is followed by 
an increased activity of the moving powers of the heart, without, 
however, restoring the healthy capillary circulation ; and that this 
increased action is apt to be followed by a failure of the action of the 
heart and large vessels, threatening death from asthenia and syncope ; 
though this latter mode of death may also arise from inflammations 
prolonging the fever, or inflicting injury upon some vital organ. 



INTEKMITTENT EEYEE. 

A paroxysm of ague or intermittent fever has generally been 
regarded as an epitome of a continued one, and for this reason most 
authors commence the subject of fevers with the consideration of 
intermittents. 

The first invasion of a paroxysm of intermittent fever, or ague, as 
it is commonly called in this country, is marked by those symptoms 
which have been already described as belonging to the commence- 
ment of the febrile state, but with great intensity. These are lassitude, 
pains in the limbs, giddiness, with a sense of weight or oppression 
about the epigastrium. The patient then begins to feel chilly, and 
have a sense of coldness down the back, the extremities become cold, 



AGUE — ITS DIFFERENT FORMS. 489 

the fingers shrunken, and the nails blue, the skin is shrivelled, and 
the papillae become prominent, constituting what is commonly termed 
goose-skin, or more learnedly cutis anserina; and the countenance 
also is shrunken, the nose cold, the patient shivers, and his teeth 
chatter, and he is glad to draw close to the tire, or envelope himself in 
blankets. He not only is cold, but he, feels cold, and acts accordingly. 

The pulse is sometimes frequent, but always feeble ; there is appa- 
rently a failure of the moving powers of the blood, which seems 
scarce to reach the surface. The tongue is white and dry ; there is 
but little urine secreted, and the bowels are confined : after this state 
of things has continued for a greater or less length of time, the heat 
of the surface begins to return, the patient has flushings of heat and 
becomes warmer and warmer, and ultimately the whole surface is of 
a dry, burning heat ; the shrivelled and livid extremities resume their 
natural colour, and even become turgid : he has at the same time 
intense thirst, restlessness, and severe headache ; the urine is scanty, 
high-coloured and turbid, and the tongue furred and dry ; the pulse 
frequent, full, and strong. After the second or hot stage has con- 
tinued for some time, another change comes over the patient ; a mois- 
ture gradually appears upon the face and forehead, the harsh and hot 
skin becomes soft, and at last a copious sweat breaks out over the 
whole surface, affording him great relief. There is also a copious 
discharge of urine, which however is still high-coloured, and the 
several functions of the system return to the condition in which they 
were before the commencement of the paroxysm. After a certain 
period of intermission, the paroxysm recurs, the time between the 
commencement of one paroxysm and the commencement of the next 
being termed the interval, and it is from the length of this interval 
that the different forms of intermitting fevers receive their names. 
Thus, when a paroxysm recurs daily, the ague or intermittent is said 
to be a quotidian ; when every alternate day it is termed a tertian, 
the day on which the former paroxysm occurred being included and 
reckoned the first. When again the paroxysm recurs after an inter- 
val of three days, or on the fourth day, including that on which the 
former paroxysm occurred, it is termed a quartan. 

There are indeed other forms of intermittents in which the interval 
is longer, and which have been named quintans, sextans, septimans, 
&c, but these are not so regular in the recurrence of the paroxysms, 
which are apt to return at such uncertain intervals, as to lead to the 
belief that they are irregular varieties of the more ordinary forms of 
the disease. Sometimes, again, the paroxysms will recur daily, but 
with those on the alternate or tertian days corresponding to each 
other in severity, duration, character, or time of invasion. In these 
cases the patient is said to be affected with a double tertian ; or again, 
there may be a paroxysm occurring on two consecutive days, leaving 
only one day of intermission ; but in these cases those in the quartan 
days correspond in character with each other, and when this happens 
the disease is said to be a double quartan. Another form of double 
or even triple quartan is when the paroxysm observes the quartan 
days, but there are two or three paroxysms on each of those days. 



490 AGUE. 

There is much variation in the duration of the paroxysm in differ- 
ent subjects, and even of the different paroxysms in the same case, as 
the time occupied by the whole paroxysm may vary from three to 
sixteen hours, the average being about four or five ; the same also 
applies to the different stages of the paroxysm. The cold stage may 
pass off in less than an hour, or it may be prolonged for several, 
though about two hours may be said to be the average duration ; and 
the same uncertainty attaches to the hot and sweating stages. It is, 
however, remarked as a general rule, that the longer the cold stage 
the shorter the paroxysm, and the shorter the interval the longer the 
paroxysm. Thus the quotidian has the shortest interval and shortest 
cold stage, but the longest paroxysm ; the tertian a longer interval 
and longer cold stage, with a shorter paroxysm ; and the quartan with 
the longest cold stage has the shortest paroxysms. 

Another curious rule, though one by no means without excep- 
tion, is, that the shorter the interval the earlier in the day does the 
poroxysm take place. Thus the quotidian paroxysm generally com- 
mences in the morning, the tertian about noon, and the quartan in 
the evening. 

The pathology of intermittent, as of all forms of fever, is neces- 
sarily obscure. We are aware from observation that during the cold 
stage there is great congestion or accumulation of blood in the great 
reservoirs, the liver, spleen, and large veins, a state of things which 
we know will arise when the action of the heart is very feeble ; so 
that it is by no means certain that this internal congestion is anything 
beyond the immediate result of the diminished force of the moving 
powers of the blood. The cold stage has by many been regarded as 
the cause of the hot ; but that it is so, further than that, in general, 
any state being at any time the effect of that which preceded, 
cannot be received as proved ; since we find that there is no certain 
relation whatever between the intensity and duration of the cold 
stages and those of the hot. The hot skin, thirst, scanty urine, head- 
ache, &c, of the hot stage are perhaps to be explained by the difficult 
capillary circulation with the consequent increased force of the heart's 
action, and arrest of secretion, arising from the loss of the affinities 
between the blood and the tissues, and which we believe to be essen- 
tial to the febrile state. There is perhaps less difficulty in accounting 
for the sweating stage by the increased force and frequency of' the 
heart's action, and gradually returning capillary circulation, though 
whether this perspiration is critical, and therefore by restoring the 
blood to its formal condition restores also the healthy relation be- 
tween the blood and the tissues, or whether this previous subsidence 
of the febrile action is the cause of a free capillary circulation, and 
consequently more copious secretion, is a question which will be 
answered according as the belief may happen to prevail that the 
miasm acts mainly upon the blood, or the nerves. 

It is unprofitable to theorise where we know so little. It may, 
therefore, suffice to remark : that if it be assumed that the malarious 
poison acts purely by impression upon the nerves, without necessarily 
being taken into the circulation, the recurrence of the paroxysm 



PATHOLOGY. 491 

must be accounted for solely by that hitherto unexplained tendency 
to periodicity, which is so remarkable in many of the animal func- 
tions ; but that we shall be quite unable to explain the circumstance 
of the morbific agency remaining, as it often does, long dormant in 
the system, until called into action by some favouring state of the 
system ; whereas, if we assume the poison to be received into the 
circulation, and in virtue of its presence there to produce the pheno- 
mena of the disease, we shall frame a more plausible theory of inter- 
mittent fevers, referring the cold and congestive to the action of the 
poison destroying the affinity between the blood and the tissues in 
the capillary circulation, and thereby causing congestion of the 
internal organs ; the hot stage again being the effect of the reaction 
from this state of congestion, which induces the sweating stage, in 
which the poison that has been accumulating in the system since the 
preceding paroxysm is eliminated from it, whereby the patient is 
restored to health, till an accumulation again takes place sufficient to 
produce a paroxysm. But in order to receive this explanation, we 
must also admit the possibility of the poison being generated in the 
system, since paroxysms will often continue to recur in those who 
are removed from the malarious atmosphere; and although we have 
no difficulty in believing this of poisons which are in the first in- 
stance of animal origin, we cannot readily admit it of those which are 
not so. 

The alone cause of intermitting fever is miasm, of which we know 
nothing excepting its effects. This miasm emanates from marshy 
lands, and is supposed to be generated by the decomposition of 
vegetable matter. There is, however, reason for believing that it 
may be produced in certain soils when saturated with moisture, but 
in which there can be no vegetable decomposition taking place. As 
regards the propagation of the disease by human intercourse, it may 
be confidently asserted that in this climate it never is so ; though 
under certain circumstances in hot climates the intermittent fevers 
may in many of their symptoms, as well as in the tendency to 
putrescency of the blood, approach more nearly to the lowest and 
most malignant forms of continued fevers, and excite a suspicion of 
their also acquiring that most important property of continued fevers, 
namely, that of spreading by contagion. 

Passing by, however, these exceptional cases, we proceed to ob- 
serve that the diffusion of this miasm is regulated by certain laws, 
both as regards the conditions external to those who are exposed to 
its influence, and their state of system at the time ; these latter have 
been miscalled predisposing causes. 

As regards the laws which regulate the diffusion of the miasm : 
the most powerful agent is heat, the virulence of the miasm being 
nearly proportionate to its intensity — though occasionally epidemics 
of unusual virulence do occur which cannot be accounted for in this 
way — the poison does not readily diffuse itself through the atmos- 
phere, nor rise to any considerable height above the surface of the 
ground, the inhabitants of the upper stories of houses often enjoying 
a greater immunity than those beneath them. The malaria is more 



492 AGUE. 

dangerous, and therefore more active, in the night than in the day 
time, and from this it has been inferred that though the heat of the 
sun's rays favours the evolution of the miasm, it afterwards dissipates 
it, though it is possible that the greater activity of the poison in the 
night may be owing to the presence of the dew. The poison is also 
wafted by the winds, being more virulent to the leeward than the 
windward of marshes, and apparently attracted and even stayed in 
its progress by trees, so much so that not only is the immediate 
vicinity of woods dangerous, but a number of trees intervening be- 
tween a marsh and a village appears to afford its inhabitants protec- 
tion. It is apparently neutralised by passing over the sea, and its 
virulence diminished by the cultivation of waste lands. As regards 
those exposed to its influence, it has been ascertained that the per- 
manent inhabitants of a malarious district are less susceptible of the 
effects of the poison in producing intermittent fever, though they 
appear to suffer from its agency in a more chronic form, being sallow, 
anemic, and often affected with visceral disease. 

There are, again, certain conditions in the individual which render 
him more susceptible of the agency of the poison, and which havo 
been therefore called predisposing causes of intermittent fever, though 
they were never known of themselves to give rise to any form of 
that disease. Thus it acts, like all other causes either of inflamma- 
tion or idiopathic fever, more powerfully upon those whose strength 
has been impaired by intemperance, fatigue, privation, excessive 
evacuations, or depressing mental emotions; whereas all agents, 
whether physical or mental, which permanently strengthen the sys- 
tem, are the most efficacious in enabling it to resist its influence. 
Exposure to great heat or cold, the remaining in wet clothes or with 
damp feet, and standing upon damp ground, exposure to watery ex- 
halations, and especially to dew, are formidable adjuvants to the 
action of the malaria. 

In hot climates the whites are far more susceptible of the effects of 
malaria than the blacks. 

The poison when imbibed appears to lie latent for an indefinite 
time — in the agues of this country often for six or nine months ; and 
it is remarkable that after its effects have for a time ceased to mani- 
fest themselves, or have not yet made their appearance, it will be 
called into action by any of those conditions of the system which 
constitute a susceptibility of its action. 

Besides the morbid changes in the liver and spleen, which are so 
frequent as to appear almost the necessary consequence of ague, if 
allowed to exist for any length of time, we have not unfrequently 
superadded some local affection, not so specific or uniform, the effect 
of the same cause, giving rise to what is termed complicated ague ■; 
such complications being generally seated in the head, the chest, or 
the abdomen. — Symptoms of congestion, irritation, or even inflamma- 
tion of the brain or its membranes have not unfrequently supervened 
in the progress of ague, giving rise to pains in the head, stupor, coma, 
delirium, or convulsion. Inflammatory affections of the chest, such 
as bronchitis, pleurisy, pneumonia, or even pericarditis, and present- 



PKOGNOSIS AND DIAGNOSIS. 493 

ing the ordinary signs of these affections, though in a somewhat 
subdued form, are liable to occur in winter and the early spring. — 
The abdominal complication is, however, the most common, and 
prevails most during the summer and autumn : it may amount to no 
more than congestion of the mucous membrane of the canal, as- 
sociated with depraved secretion from the liver, exciting sickness and 
moderate purging. In other cases, however, there is more decided 
inflammation either of the intestinal mucous membrane, of the liver, 
or of the spleen. 

The prognosis of ague is to be considered first in reference to the 
immediate safety of the patient, and next to ultimate restoration to 
health. As regards the first question, there is little or no immediate 
danger to be apprehended from agues occurring in persons whose 
constitutions are naturally sound, and have not been impaired by 
age, disease, or irregular habits ; and this is still more the case if the 
disease be tertian or quartan, and occurring in the spring ; but, on 
the other hand, where the constitution has been weakened by any of 
the above-mentioned causes, there is great danger of death from 
sinking under the general disturbance set up by the disease ; and 
this is still more likely to ensue in the autumn, and if the ague be a 
quotidian, or attended with disturbance in the alimentary canal. 
Upon the whole, however, it rarely happens that a person dies in 
this country, either in the paroxysm or during the continuance of 
the intermittent. As regards the second point, however, the prognosis 
is not so satisfactory, since it by no means follows, that because the 
paroxysms have ceased to recur, therefore a perfect cure has been 
effected, and the patient rendered safe from the ill effects of the ague 
and the miasm which excited it: for we know that during the cold 
stage there is great congestion of the liver and spleen, of the latter more 
especially; so much so as in some instances to have caused death by 
rupture of the organ from over-distension. The effect of this frequent 
congestion is an induration of one or both of these organs, of the latter 
so frequently that the enlarged spleen is familiarly known by the 
name of "ague-cake;" and we know that the immediate effect of 
these indurations is obstruction to the passage of blood through the 
veins converging to the vena portae, and its remote consequences — 
diarrhoea, dysentery, and dropsy. We have reason to believe also 
that there is a connection between the action of the miasm and the 
sallow, bloodless aspect so often observed in those who have been 
the subject of intermittent; whether this anaemic condition be 
brought about through the agency of the diseased spleen, or whether 
both are to be regarded as the joint effects of the poison; and we 
know that such persons may have the visceral diseases consequent 
upon ague, even passing on to their fatal termination, without ever 
suffering a paroxysm of intermittent; showing that these results are 
to be ascribed rather to the action of the poison than the actual 
development of ague. Whilst, therefore, there is any enlargement 
of the spleen or liver, or any tendency to derangement of the ali- 
mentary canal, and whilst the patient continues weak and retains the 
sallow aspect, and until he has recovered his appetite and strength, 



494 AGUE. 

we cannot regard him as altogether secure from the dangerous sequels 
of the disease. 

In general there is no great difficuly in the diagnosis of ague ; the 
only disease with which it is liable to be confounded being hysteria, 
hectic and febrile paroxysms arising from certain local irritations; 
hysterical females occasionally experience attacks of shivering, fol- 
lowed sometimes by a hot and even a sweating stage; but these 
paroxysms are so irregular as to their recurrence and their progress, 
that the knowledge of their liability to recur, is sufficient to prevent 
their being mistaken for ague. 

Hectic fever often simulates a quotidian, and sometimes, though 
rarely, a tertian; but there is this difference, that in hectic the cold 
stage is very slight, sometimes altogether wanting ; there is a liability 
to transient feverishness at all times, with a pallor of the countenance, 
displaced occasionally by a circumscribed flush, very different from 
the sallowness produced by the ague miasm. In hectic, too, the 
shivering, when it occurs, generally comes on towards evening, and 
the sweating in the morning; in this respect also differing from what 
has been before stated to be generally though not uniformly the case 
with regard to the time of invasion of a quotidian paroxysm. The 
existence of suppuration in some part, and the rapid emaciation, are 
additional diagnostic circumstances in hectic. 

Severe rigors, followed by heat and sweating, are also induced by 
stricture of the urethra, diseased prostate, and the passage of calculi 
along the gall-ducts or ureters; and these paroxysms, though irre- 
gular in the periods of their return, so closely simulate those of ague, 
that the possibility of the existence of one of these causes ought always 
to be carefully inquired into. 

In the treatment of intermittent, as of all idiopathic fever, we must 
bear in mind the tendency to spontaneous recovery, when the imme- 
diate cause of the disease has been eliminated; and therefore one of 
the first things to be done, where it is possible, is to remove the 
patient beyond the sphere of the malarious poison. It is also found 
by experience that anything producing a considerable impression 
upon the system at large, or strongly affecting the mind of the 
patient, will have the effect of preventing a paroxysm or greatly 
lessening its severity; for this purpose emetics have often been 
beneficially employed; the ordinary emetic* (F. 91) may be admin- 
istered, or half a drachm of sulphate of zinc given in the same way, 
before the time of the expected paroxysm. The application of a tour- 
niquet, so as to arrest a considerable portion of the circulation, has 
also not uncommonly prevented or diminished the paroxysm. And 
the same result has even been produced by swallowing some cob- 
web or a live frog. 

The treatment of ague may be divided into that during the 
paroxysms, and that in the interval ; and upon the principles already 
laid down, we must perceive that the former can be merely pallia- 

* (91) R. Pulv. Ipecac. 9 j. 

Antim. Pot. Tart., gr. i. M. 



TREATMENT. 495 

tive, and that the latter should be directed towards removing or 
counteracting the cause of the paroxysm. 

During the cold stage the patient should be placed in a warm bed, 
with warm pans or bottles of water ; he may be allowed the free use 
of warm drinks, and if he be not of a plethoric habit, moderate sti- 
mulants, as negus or white-wine whey, may be used in order to pro- 
mote reaction, and shorten the cold stage. It has been recommended 
to bleed during the cold stage, a practice eminently dangerous, and 
based upon the mistaken idea that the congestion in the internal 
organs is the cause and not the effect of the diminished force of the 
heart's action. 

In the hot stage the coverings should be diminished, and cooling 
drinks, as lemonade or common effervescing saline draughts, admi- 
nistered, or compound infusion of roses with a little nitre. It is 
during the hot stage that opium has been found particularly service- 
able, unless contra-indicated by well-marked local inflammation or 
congestion, Twenty or thirty minims may be administered, and will 
generally have the effect of speedily inducing a profuse perspiration. 
Bleeding in this stage, though it may give some temporary relief, is 
not to be recommended, since by impairing the powers of the patient 
it counteracts the treatment which is to be adopted in the interval. 

In the sweating stage there is no occasion for any treatment 
beyond care to avoid checking the perspiration by premature expo- 
sure. 

It is, however, during the intermission that remedies are to be 
employed to eliminate the poison or counteract its effects, and pre- 
vent the return of the paroxysm ; and for this purpose, more especi- 
ally the latter, tonics have been found most efficacious. Of these, 
the most important and most generally employed is Peruvian bark, 
or its alkaloid, the quinia in the form of one of its salts. There are 
two ways of administering these drugs — the one is by giving a full 
dose shortly before the expected paroxysm, when it will often have 
the effect of preventing its occurrence altogether. This practice is 
often recommended in the ague districts as curing the disease with 
the least possible expenditure of quinia or bark ; it has, however, the 
disadvantage of the cure often not being permanent, the paroxysms 
returning after the omissions of several periods. When, however, 
we are particularly desirous of preventing the occurrence of a parox- 
ysm which is near at hand, twelve grains of sulphate of quinia may 
be administered, or, as some recommend, half an ounce of powdered 
bark, though the latter is more offensive to the patient. 

The most efficient means of counteracting the effect of the poison, 
is to administer the bark or quinia in divided doses, throughout the 
intermissions. The most convenient form is to give the sulphate in 
doses of from two to four grains every three hours, the dose being 
greater for a quartan than a quotidian. Some writers rather fanci- 
fully recommend two grains for a quotidian, three for a tertian, and 
four for a quartan ; the dose may be increased should there be no 
complication contra-indicating it, and should the paroxysm not be 
delayed or mitigated. 



496 AGUE. 

Another most important remedy, which has been known to suc- 
ceed when bark and quinia have failed in removing an ague, is 
arsenic ; the form in which it is most conveniently administered 
being four or five minims of the liq. pot. arsenit. of the Pharmaco- 
pcea, three or four times a-day, as many of tincture of opium or a 
drachm of syrup of poppy being added, in order to prevent griping 
or irritation of the bowels ; but should the bowels by this means be 
confined, the use of a gentle laxative, such as about two drachms of 
castor- oil, will be preferable to withdrawing the opiate. The dose of 
the arsenic may be cautiously increased. Should redness of the con- 
junctivas or other signs of an over-dose be perceived, the remedy 
should be immediately withdrawn, or the quantity diminished. 
Most authors recommend that the arsenic should be administered 
during the intermission ; but Dr. Pereira states that he has repeat- 
edly used it with good effect during the paroxysm, and that it is 
not, like quinia, contra-indicated by the presence of inflammatory 
complication. 

Arsenic is a tasteless remedy, which is not unimportant in the 
treatment of ague in children, and is, moreover, a cheap one, which 
is no inconsiderable advantage when we consider the great scarcity 
and almost necessarily limited supply of quinia, and its consequent 
liability to adulteration ; and take into account the numbers of a poor 
population who are frequently affected in ague districts. On the 
other hand, it must not be forgotten that arsenic is a poison, which 
quinia is not, and that although it has been stated to be a tonic, there 
is little ground for supposing it to be so, beyond the simple fact of 
its stopping the paroxysms of ague and periodic neuralgia. Other 
tonics have been recommended for the cure of ague, though none can 
bear comparison with the above as to their power over the disease ; 
from the vegetable kingdom there are the willow bark and salicine ; 
the cusparia bark, which contains cinchonia ; the acorus, or calamus 
aromaticus ; the gentian, &c. : and from the mineral, zinc and copper, 
the former of which has perhaps hardly been tried as fully as it 
deserves. 

But whatever be the remedy employed, it is to be remembered 
that the paroxysms after they have apparently ceased for a consider- 
able time, will often return ; generally upon a clay on which one would 
have taken place had there been no interruption to their recurrence ; 
and therefore it is necessary to continue the remedy for some days 
after the disease has apparently subsided. 

There is no doubt that a loaded state of the bowels, or congested 
condition of the liver, interferes with the beneficial effects of quinia or 
arsenic ; and therefore it is often expedient to administer a moderate 
mercurial purgative before commencing the remedy to be employed 
in the intermission, whenever there is the least suspicion upon this 
point. 

An ingenious suggestion has lately been made, that quinia and 
arsenic act mainly as antidotes, counteracting the agency of the 
poison, but not removing it ; and, therefore, that it would be most 
desirable to find some means of eliminating the poison from the sys- 



COMPLICATIONS — PREVENTIVE TREATMENT. 497 

tern ; for this purpose saline diuretics have been recommended, and 
particularly the acetate of potass. It does not appear, however, that 
this remedy can be relied on for preventing the paroxysm, though it 
did so in two of several cases thus treated at Guy's. Where, how- 
ever, the order of the paroxysms had been broken by quinia, it cer- 
tainly seemed to promote convalescence. 

The treatment of complicated ague must, of course, depend mainly 
upon the nature of the complication. We have already noticed the 
tendency to congestion in the liver and spleen, which is in some 
decree induced in all who continue Ions: within the influence of the 
malaria, even should they not become actually the subjects of ague, 
but which is aggravated tenfold by the occurrence of paroxysms: 
therefore the occasional use of a mercurial purgative — e. g. three 
grains of calomel with twelve of rhubarb — is not only an almost 
necessary preliminary to the treatment of ague, but ought to be re- 
peated every second or third morning, in those who have been long 
exposed to the poison. When diarrhoea is present it will in general 
be restrained, and the state of the alvine evacuations corrected by 
two grains of the hydr. cum cret., with four of the pulv. ipecac, co., 
or eight of the pulv. cret. co., night and morning ; accumulation in 
the intestines being guarded against by occasional doses of two 
drachms of castor-oil, or the combination of rhubarb and chalk, the 
lower bowels being emptied when necessary by injections of gruel; 
and it is to be observed that in all cases we shall gain nothing by the 
use of bark, but rather produce head-ache, thirst, and loaded tongue, 
if it be administered before these abdominal derangements have been 
removed ; where there is much tenesmus with diarrhoea, the cusparia 
will be found a very useful preliminary to the exhibition of the bark. 
It is to be remembered too, that it is in such cases that the arsenic is 
peculiarly serviceable, not being likely to produce the same local 
irritation or general excitement that we may apprehend from the 
cinchona. , 

The enlarged spleen, which is so common a complication or rather 
consequence of ague, will best be treated by moderate laxatives and 
local depletion, either by leeches or cupping-glasses ; poultices and 
occasional blisterings, iodide of potassium, and occasionally quinia or 
bark, and by mercurial plaster, or the combination of equal parts of 
mercurial ointment and the compound iodide ointment, and, above 
all, by a rigid avoidance of exposure to the malarious influence. 

This latter precaution is indeed essential in all cases of convalesc- 
ence from ague, as is also the avoidance of damp atmosphere, getting 
the feet wet, and all those circumstances which induce a chill to the 
system. Besides this, gentle tonics, as the infusion of calumba or 
cascarilla, or even a grain of the disulphate of quinia in infusion of 
orange-peel, with two minims of diluted sulphuric acid, may be 
administered twice in the day. 

There is no disease in which prophylactic treatment is of more 
importance than in ague, and this remark applies more particularly 
to those who have been affected by it, since such persons, not merely 
during convalescence, but even through life, evince a tendency to 

32 



498 REMITTENT FEVER. 

the disease far beyond what is observed in others who have not been 
so affected ; and therefore, not only shonld they be specially careful 
to avoid a malarious locality, but all who either have had the fever 
or have been exposed to the influence of its causes, or are liable to 
such exposure, should be careful not to place themselves in those 
circumstances which have been pointed out as rendering them liable 
to their action. And those whose duties compel them, as it were, to 
set such circumstances at defiance, must use every precaution to coun- 
teract or diminish their agency; such, for instance, as never going 
out at night, or very early in the morning, unless compelled ; and in 
the latter case not going out fasting ; sleeping as far removed from 
the soil as possible ; choosing, when it can be done, a situation 
screened by trees from that in which the poison seems most rife ; 
avoiding all excesses, but living moderately well, or rather more 
generously than is the ordinary habit. Moderate doses of quinia, 
with the occasional use of a warm aperient, such as the compound 
decoction of aloes, is a useful safeguard for those who are travelling 
through an ague district, or temporarily residing in one. 

Remittent fever arises, like intermittent, from malaria ; and as met 
with in this climate is generally a modification of the latter, produced 
either by exposure to malaria in a concentrated or very active form, 
or by certain circumstances affecting the individual, and rendering 
him peculiarly susceptible of its action ; as cold, heat, or vicissitudes 
of temperature, or some source of irritation, generally in the liver or 
intestinal canal, which by tending to keep up the febrile state, pre- 
vents the complete apyrexia of an intermission. 

In some cases the invasion of a remittent is preceded by the ordi- 
nary premonitory signs of fever. It more commonly, however, com- 
mences rather suddenly, with chills, especially a feeling of coldness 
along the spine, sometimes actual rigors, depression of spirits, and 
anorexia, pain in the back and limbs, headache, or confusion of 
intellect. Febrile reaction then- follows, marked by dry heat, flush- 
ing, thirst, increased headache, hurried respiration, a frequent, full, 
and sometimes hard pulse, dry, white, and furred tongue. There is 
also at the commencement of the reaction a sense of weight about 
the epigastrium, with a feeling of constriction, and even pain, in- 
creased most commonly by pressure, and often attended with nausea, 
and perhaps vomiting — symptoms indicative of congestion about the 
preecordial region ; the urine being scanty and high-coloured ; and 
the stools, for the most part, of a dark bilious character. 

This state of active fever may continue for a very variable period ; 
sometimes not so long as eight hours, at others fourteen or sixteen, 
when the symptoms gradually subside, and a greater or less amount 
of perspiration ensues, much as the sweating supervenes upon the 
hot stages of regular intermittent. After this the patient feels much 
relieved, but is never altogether free from febrile excitement, and 
after an uncertain interval experiences a recurrence of the febrile 
symptoms, sometimes preceded by a cold stage which is scarcely 
perceptible ; at others by distinct chills, or even well-marked rigors. 

This fever admits of many degrees of severity ; from a chilliness 



CAUSES — DIAGNOSIS. 499 

felt once in the twenty -four hours, followed by slight febrile reac- 
tion, to a fever in which the remissions are so slight as to assimilate 
the disease to severe continued fever. 

The cause of remittent fever has been already pointed out to be 
nearly the same with that of intermittent, the result being modified, 
either by a variety in the character of the miasm or the state of the 
subject, and it is, when the causes of both continued and intermittent 
fevers are in most active operation, and also when there is the great- 
est tendency to abdominal derangement, that remittent fevers are 
most commonly met with ; namely, in the autumn and in places 
where, besides the ordinary malaria, there are the effluvia emanating 
from sewers, stagnant ditches, and receptacles of decomposing animal 
and vegetable matter. So closely, indeed, does the remittent fever 
so excited often approach to typhus, that it may really become true 
typhus, and is, perhaps, under such circumstances, capable of repro- 
ducing itself bv contagion. 

It is not difficult, neither is it perhaps a matter of much practical 
importance, to form a diagnosis between intermittent and remittent 
fever ; the greater difficulty, in some forms of remittent, is that which 
is of much more consequence to the safety of the patient — to distin- 
guish this disease from continued fever, to which, as we have seen, 
it may approach so nearly. 

It is, then, chiefly by inquiring into the history of the disease, and 
watching its progress, that we can hope to discriminate between the 
two. If, for instance, the patient has been in a malarious district, if 
there be no maculae to be discovered on any part of the body, and if 
the case occurs in the autumn, or at a time when intermittents are 
prevailing, we may generally find that the fever has a miasmatic 
origin, and will probably evince a remitting character, a suspicion 
which will be brought almost to certainty if upon careful watching 
we discover that at some time there occurs a chilliness, followed by 
increased pyrexia, relieved by sweating. On the other hand, as we 
shall presently see in continued fever, complicated with much gastric 
irritation, we often have that disease assuming the character of irreg- 
ular hectic, somewhat resembling remittent ; from which, however, it 
may be distinguished by the character of the evacuations, the cir- 
cumscribed flush on the cheek, and the previous history of the 
disease. 

In autumnal seasons following unusually hot summers, remittent 
fever, occurring in patients of debilitated constitutions, or already 
labouring under visceral disease, may sometimes prove fatal ; but in 
general, as it occurs in temperate climates, it is attended with little 
or no danger, beyond the remote consequences which attach to it as 
a form of ague ; indeed the remittent fever of such climates may be 
said-^to be dangerous only in proportion as the season and circum- 
stances under which they occur approach to those of intertropical 
countries, where there is a rapid production and decay of vegetable 
matter, and the system is rendered peculiarly susceptible of malari- 
ous poison, owing to the depressing influence of an almost vertical 
sun ; and where the remittent fever is at all times a severe and often 



500 REMITTENT FEVER. 

fatal disease, "but peculiarly dangerous to Europeans lately arrived 
from temperate climates. 

We have already spoken of the importance of the distinction be- 
tween continued and remittent fever, and towards assisting in the 
diagnosis, the treatment may often be made subservient. The first 
object in the use of remedies should be, where the remission is 
obscure, to render it more distinct ; and where it is tolerably so 
already, to convert it into an intermission. This will generally be 
effected by removing the irritating cause which has converted the 
intermission into a remission ; therefore, the first thing to be done is, 
to explore carefully the abdomen, and if there be pain and tender- 
ness in the region of the liver, tenderness or flatulence of the bowels, 
our remedies should at once be directed to those organs. Where 
the tenderness of the spleen or liver is great, and there is tolerable 
firmness of the pulse, a small quantity of blood may be taken by 
cupping, or by a few leeches, from the region of the affected organ : 
but, as a general rule, unless the inflammatory symptoms be decided 
and severe, it is better to await the effect of a moderate laxative, such 
as may have at the same time the effect of correcting the secretions 
into the intestinal canal. 

For this purpose, the best will be about five grains of hydr. cum 
cret., followed, in four hours, by three or four drachms of castor-oil ; 
or if the oil would be likely to offend the stomach, the combination 
of calomel and rhubarb may be employed. When the bowels are 
very irritable, about two grains of hydr. cam cret. with six of pulv. 
cret. co., may be given two or three times daily ; and if it be thought 
necessary to remove offending matter from the lower bowels, a pint 
of gruel may be given in the way of glyster. It will ordinarily 
happen, after the use of these remedies, that the remissions will be- 
come more distinct, or be converted into well-marked intermissions. 
Indeed, it is no very uncommon occurrence for cases brought into 
the wards of our hospitals, closely resembling continued fever, to put 
on a distinctly remittent or intermittent form after the action of a 
laxative, such as has been recommended above ; and as a general 
rule it will be by far the safest course to defer even local depletion 
till such means have been tried ; and with regard to general bleeding, 
although recommended as a preliminary measure by some of the 
older authors, it is certain that, unless there be evidence of active 
inflammation, with a hard and moderately full pulse, it is not well 
borne by patients such as now ordinarily present themselves with 
remittent fever. So important, on the other hand, are means for 
removing local irritation, that they will (often have the effect not 
only of establishing an intermission, but even of removing the fever 
altogether. 

Cases have already been mentioned in which the intermission 
appears to have been prevented, and the febrile state kept up, by 
impure air, and effluvia from decomposing animal matter, and it may 
be by the contagion of continued fever ; in such cases we often find 
the removal to a purer air, as from a confined dwelling to the ward 
of a hospital, speedily has the effect of bringing back the intermitting 



CONTINUED FEVER. 501 

character. After 'the more active fever has been subdued, and the 
causes of local irritation removed, mucilaginous drinks and salines, 
as the liquor ammon. acetat. or citrate of potass, may be employed, 
under which treatment the remissions will gradually develop e them- 
selves into intermissions, and the disease may be treated as an inter- 
mittent ; though, even before this, when the remissions are considera- 
ble, and particularly in debilitated subjects, we may venture upon 
the use of the quinia, even when a somewhat loaded tongue, with, 
increased frequency of pulse, would, under other circumstances, 
contra-indicate its employment. 



CONTINUED FEYER. 

There are several forms of fever which, according to strict nosolo- 
gical arrangement, ought to come between the intermittent, the remit- 
tent, and the continued fever, yet as these three constitute, in a mea- 
sure, the typical forms of fever, or at all events those which are 
generally regarded as standards of comparison by medical men in 
this country (owing, perhaps, to their greater familiarity with them), 
we proceed at once to the consideration of continued fever, more for 
the sake of practical convenience, than in accordance with, any sys- 
tem. 

As regards continued fever itself, it has been the custom to speak 
of varieties of this disease; and the same is common both with the 
profession and the public: thus we hear of typhus, putrid, bilious, 
nervous, and brain fevers; and more technically, if not more scien- 
tifically, of adynamic, atonic, mucous, gastro-enteritic, &c. Yet, not- 
withstanding that continued fever does assume these different phases, 
and notwithstanding that an attempt has of late been made with. 
much ability to prove that there are at least two forms of it, arising 
from distinct poisons, it will be found most convenient for practical 
purposes to follow the course indicated by Dr. Watson, of including 
different forms under the general term of continued fever, and treat- 
ing of them as varieties or complications of that disease. 

An attack of continued fever does not always commence in the 
same way: in a large number of cases there is a previous drooping, 
or sinking of health, going on for days, or even weeks ; the patient 
feels languid, indisposed for his ordinary employments or amuse- 
ments; his appetite fails, his tongue becomes white or creamy, his 
bowels irregular, and his senses are often less acute; he is anxious, 
or drowsy, it may be, in the daytime, and his sleep is disturbed, and 
he wakes unrefreshed in the morning. 

In a large number of cases, however, these premonitory signs are 
altogether wanting; the patient is more suddenly attacked; often 
there is at first, shivering, sickness, severe headache, or pain in the 
back, and in some cases the disease has commenced with syncope ; 
there is also a state of general oppression, with the appearance of 
which every one must be acquainted who has made several visits to 
the bedside of a patient in this early stage of the disease; the tongue 



502 CONTINUED FEVEE. 

is either covered with a white fur, or there is a brownish streak, cleft 
in the middle, running along the dorsum; the pulse is commonly 
frequent, but compressible. 

This stage of oppression passes more or less quickly into a state 
of fully-developed fever. The skin becomes hot, often for a day or 
two pungently so, particularly in children; the pulse more frequent, 
fuller, and sharper, ranging generally from 100 to 120; the tongue 
is commonly injected at the tip and edges, furred towards the centre, 
with a disposition to become dry, and there is increased thirst and 
clamminess of the mouth. There is also increased oppression, and 
pain in the head, back, and limbs; and we see more fully marked 
the depressed and desponding, yet at the same time almost apathetic 
countenance, characteristic of continued fever; the conjunctivae are 
injected; there is also commonly a weight and tenderness on pressure 
at the epigastrium; the bowels are, at this period, generally torpid, 
though sometimes irritable, and the urine is scanty and high-col- 
oured; there is restlessness, and sometimes delirium at night. 

It is often at this period of the fever, or it may be later, that an 
eruption shows itself, either in the form of lenticular, slightly elevated, 
rose-coloured papulae, or less elevated, and more irregularly shaped 
maculae, generally showing themselves first over the breast and abdo- 
men, or commencing first about the insertion of the pectoral muscles; 
though in slighter cases the eruption is altogether absent. 

In the milder cases, and under careful treatment, and sometimes 
without any treatment at all, these symptoms will gradually subside, 
leaving the patient feeble, and generally with more or less loss of 
flesh ; the convalescence commencing sometimes as soon as the tenth 
day, and in children even earlier, but in adults it is not generally 
fairly established before the end of the second, and sometimes the 
third week. Sometimes, however, the disease assumes a severer 
form, either suddenly, when the progress had hitherto appeared 
favourable, often without any assignable cause, but at other times 
from injudicious management; or it may from the first evince an 
almost malignant character. 

In a large number of those cases in which the fever unexpectedly 
assumes the severer type, the unfavourable symptoms generally 
show themselves from the seventh to the tenth day, or even later, 
about the time at which, in the milder ones, we may expect to see 
some signs of amendment, — the countenance becoming more anxious 
and shrunken, the tongue dryer, the fur, which had before been 
drab-coloured, becoming brownish, and assuming more the character 
of a coating, the pulse quicker and sharper, but at the same time 
more compressible; and the patient, who before might have lain 
indifferently on either side, remains in a supine position. 

The delirium which, if it existed before, was confined to occasional 
wandering on waking from sleep, becomes almost constant through 
the night, and sometimes continues during the day ; or there may 
be stupor, from which the patient is with difficulty roused, though, 
when thoroughly so, he gives a short but pertinent answer, but soon 



SYMPTOMS. 50 



D 



relapses into his former stupid state, or begins to talk incoherently, 
and continues muttering to himself. 

The senses, especially those of sight and hearing, become more or 
less disordered ; often there is apparent dimness of vision, but not 
unfrequently an obvious intolerance of light; the same is true also 
of hearing; there is frequently deafness, but on the other hand, 
intolerance of sound is not uncommon ; and even as regards feeling, 
there is often an exaggerated sensibility to touch, though this is 
more common, perhaps, in the commencement of the disease, and is 
not confined to the severer cases. The debility continues to increase, 
showing itself, as regards the nervous system, by tremors, and 
twitching of the limbs and of the tongue, which sometimes is pro- 
truded with difficulty, and sometimes is quickly thrust forward and 
drawn back again for many times in succession. The tongue itself 
is red, clean, and glazed, or otherwise of a yellowish brown, or even 
almost black "colour; the cheeks also become occasionally flushed, 
the bowels are generally loose, though at times there may be a ten- 
dency to constipation. 

This state of things may continue for even some two or three 
weeks, the pulse becoming smaller and more frequent, the tongue 
darker and dryer, the alvine evacuations passed unconsciously, and 
though the urine is retained, there may be at the same time a 
dribbling from the distended bladder; the pulse becomes more fre- 
quent and feeble, though it may almost to the last retain a certain 
degree of sharpness, or, though small, it has a slight back-stroke; 
and ultimately the patient sinks from asthenia. Or on the other 
hand, it may happen that the fever subsides ; or in other words, the 
morbific influence of the poison upon the system ceases to operate ; 
or the poison itself being eliminated, sometimes with copious evacua- 
tions, the capillary circulation is relieved, the secretions are restored, 
the tongue becomes less dry and cleaner, and the pulse soft, often 
full, and rather slow, and the patient, though in a state of great 
exhaustion and emaciation, begins slowly to recover. 

"In other cases, the change from the milder to the severer form of 
fever takes place more suddenly, and with signs of great nervous ex- 
citement, but at the same time of great debility. The patient becoming 
furiously delirious, the eyes red and fiery, the skin hot, and the counte- 
nance flushed; or there will be incoherent talking or muttering, the 
patient remaining for a time quiet, and then speaking rapidly and in 
a rambling way about his business, or whatever may be supposed to 
have been uppermost in his mind at the time of the attack ; at other 
times he will moan piteously, or utter plaintive cries, there will be 
picking of the bed-clothes, tremor, or subsultus of the muscles, and 
the tongue will be protruded tremulously and with difficulty ; the 
tongue itself being coated with a thick, pitchy mucus, which dries 
and cracks, and often causes great pain to the patient; this mucus 
adheres also to the teeth and lips, and seems to glue them together, 
extending also to the fauces, and probably likewise to the glottis, 
often exciting a teasing cough. The urine is very high coloured, and 
sometimes tinged with grumous, dark blood ; the bowels are some- 



504 CONTINUED FEVER. 

times confined, though at others relaxed, the stools loose, dark, and 
offensive. This state of things may continue for several days, the 
patient appearing all the time upon the verge of dissolution, after 
which a slow amendment commences almost imperceptibly, though, 
in a few cases, a sudden change takes place for the better on the 
supervention of a copious discharge from the skin, the bowels, or 
kidneys."* 

In a considerable proportion of cases, however, the prostration 
increases, the patient remains supine, and sinking lower and lower 
in his bed, continually muttering, but apparently insensible : some- 
times a sudden haemorrhage takes place, either from the bowels or 
by the urine, or the disorganised state of the red corpuscles allows 
the solution of the colouring matter in the serum, and its consequent 
transudation through the cutaneous vessels, producing purple or livid 
patches, and the patient ultimately sinks exhausted. 

In the forms of severe continued fever which have just been de- 
scribed, the more dangerous symptoms have been supposed to super- 
vene upon those of the milder, but many cases are essentially of a 
severe and malignant character from the first ; or speedily become 
so, either from the previous constitution of the patient, as when it 
has been impaired by exhausting diseases, fatigue, intemperance, 
venereal excesses, or protracted anxiety or distress of mind. It may 
be well here to observe, that, amongst the mental causes affecting 
the character of fever, there is reason for believing that a certain 
state of excitement induces a condition of the nervous system in which 
delirium, attended with exhaustion, supervenes early in the course 
of the disease, which is prone to run its course with unusual celerity 
and violence. Cases of this kind occur most frequently amongst the 
more highly-educated classes. 

In other cases, again, either the poison producing the disease, is 
concentrated, or the patient rendered peculiarly susceptible to its 
agency by external circumstances, or its effects are aggravated by 
mismanagement. These are the cases commonly known as malignant, 
or putrid fever, and are most frequently met with in the confined 
habitations of the poor, especially in crowded cities, where, besides 
the depressing effects of noxious effluvia, we have the concentration 
of the poison from the crowding of several infected persons in the 
same apartment, often in the same bed ; superadded to which there 
is sometimes the perverse precaution of carefully excluding the air, 
sometimes the premature administration of stimulants, and now and 
then the no less pernicious misuse of depletion. Under such circum- 
stances, we have the effects of change, almost of decomposition of the 
blood, combined with irritation and speedy exhaustion of the nervous 
system ; the former are shown by the early appearance of livid pete- 
chias or vibices, and the excretion of dark blood from the bowels or 
bladder ; and the latter by early delirium, speedily followed by coma 
or stupor. Such is the course of continued fever, viewed irrespec- 
tively of the complications or local hyperaemias to which it very 

* " Elements of Medicine." Bright and Addison. 



COMPLICATIONS OF FEVEK. 505 

frequently gives rise, and without which it may prove fatal by 
sinking or asthenia, apparently from failure of the moving powers 
of the circulation, brought about conjointly by the depressing agency 
of the poison upon the nervous system, and the loss of the healthy 
affinity between the blood and the tissues. 

The complications just alluded to are, however, particularly worthy 
of notice, as when they occur, which they very frequently do, they 
greatly affect the course of the disease, and ought proportionately to 
modify our prognosis, and also our treatment ; and a further reason 
why they deserve to be carefully looked for upon all occasions is, 
that in certain epidemics particular complications appear to prevail, 
so that having observed cerebral complication to occur in several 
cases at the breaking out of an epidemic, we may be prepared to 
expect its recurrence in others. 

Fever with predominant cerebral complication. — One of the most dan- 
gerous and not the least frequent of the complications of continued fever, 
is lesion of the brain and its membranes. That the brain and nervous 
system is always one of the parts principally affected, we have already 
seen ; though of the precise nature of this affection we may be said 
to be nearly ignorant, and are therefore justified, in the present state 
of our knowledge, in regarding it as the direct effect of the poison 
upon the nervous system ; and there can be no doubt that death may 
ensue from this cause without any evidence of inflammation after 
death; 'and though preceded by much excitement, the symptoms 
during life are widely different from those which characterise true 
inflammation within the cranium. 

Still, it is no less true that inflammation of the brain or its mem- 
branes, or of both, does frequently occur, as shown alike by the 
symptoms during life, and the results of dissection after death. There 
is intense pain in the head, with a slow, or oppressed pulse, which is 
speedily followed by great restlessness, incessant talking, and, though 
rarely, furious delirium, the pulse rising, and becoming frequent, and 
rather sharp, but generally compressible, the tongue brown and dry, 
and the skin hot; the eyes become suffused, and there is increased 
susceptibility to light and sound. This state of things may come on 
at any period of the fever, but when it shows itself early, is always 
of fearful omen ; indeed, as a general rule, early delirium is a most 
unfavourable symptom in fever, more particularly in adults, since children 
may have a certain amount of wandering at almost any period of any 
febrile disease. 

The delirium under such circumstances is less violent than in 
ordinary inflammation of the brain, and indeed here, as in all cases 
of inflammation occurring in fever, the symptoms of languor and 
prostration supervene rapidly upon those of excitement; the tongue 
becomes brown and dry, the pulse, though frequent and sharp, is 
compressible, there is a dull, staring eye, feeble voice, subsultus 
tendinum, and, unless these symptoms subside, we have moaning and 
muttering, with feeble cries, the head being rolled about in evident 
distress ; afterwards cold clammy sweats break out upon the surface, 
the urine and stools are passed unconsciously, the pulse becomes more 



506 CONTINUED FEVER. 

and more feeble, and the patient either passes into a state of hopeless 
stupor, or sinks exhausted. The appearances after death are such as 
indicate inflammatory action, though hardly fully -developed inflam- 
mation. There is increased vascularity, as shown by the appearance 
of bloody points from divided vessels in the substance of the brain ; 
and sometimes, though rarely, there is softening. As regards the 
membranes, there is increased injection of the pia mater, with sub- 
arachnoid effusion, the latter membrane being often opaque, and 
there may be effusion into the ventricles. 

In other cases, again, the poison seems to act more particularly 
upon the respiratory organs, especially the lungs and bronchial mem- 
brane, causing congestion of a more or less active character, and 
subsequently inflammation of those organs. Complications of this 
class are more frequent in the winter months, but they may occur in 
fevers at all periods of the year. When the bronchial membrane is 
the tissue principally affected, there is, early in the disease,, weight 
and oppression of the chest, dyspnoea, often an appearance of conges- 
tion about the countenance, and sometimes a tendency to lividity of 
the extremities ; the tongue is generally dark at the edges, the pulse, 
which is sometimes sharp, is almost always quick and feeble ; and 
there will in the commencement be, the dry, sibilant, or wheezing 
sound of congestion or turgescence of the bronchial membrane ; this, 
in most cases, is followed by the expectoration, and other signs, of 
bronchitis; though it sometimes happens that the inflammation, if 
such it be, stops short at the stage of congestion, and subsides with 
the subsidence of the general fever. 

The complication of pneumonia is by no means unfrequent, per- 
haps less so than is commonly supposed, from the circumstance that, 
unless attended by bronchitis, it is often latent. The fact of pneu- 
monia being often latent is one of great importance generally, but it 
is especially so in reference to the treatment of fever, and for the 
discovery, or at all events for the distinct announcement of this fact, 
we are indebted to Dr. Addison; there being neither cough nor 
expectoration, and sometimes but little excitement of the respiration, 
often not more than we ordinarily meet with in fevers. It is only 
by auscultation that it can be detected, though, when deeply seated 
and uncomplicated, it may escape even this means of diagnosis. The 
post-mortem appearances are the same as those observed in the ordi- 
nary forms of pneumonia already described, with the exception, 
perhaps, that there is a greater tendency to the effusion of serum in 
the substance of the lung. Care is to be taken after death to dis- 
tinguish the hypostatic congestion occurring towards the termination 
of fever, sometimes during the last agony, from that produced by 
true pneumonia, and the same should be observed during life ; for it 
not uncommonly happens that when a patient has for a long time 
been prostrate on his back, in a low form of fever, if he be raised, 
and the stethoscope applied to the back of the chest, the first few 
inspirations will* be attended by a sound closely resembling the dry 
crepitation of early pneumonia; though after the repetition of several 
respirations it will cease. 



AFFECTION OF INTESTINES. 507 

Perhaps the most frequent complication of continued fever, and 
one, which on that as well as other accounts, deserves most careful 
attention, is irritation and inflammation of the mucous membrane of 
the alimentary canal. That there is derangement in the upper part 
of this membrane is apparent from the state of the mouth, but it is 
not uncommon, especially at an advanced period, to see the tongue 
very red and morbidly clean, or even glazed ; and at the same time, 
there may be great tenderness at the epigastrium, with nausea and 
vomiting, which last is not unfrequently a very troublesome symp- 
tom, indicating irritation or even inflammation of the mucous mem- 
brane of the stomach, which is sometimes found on inspection after 
death. 

The part of the intestinal mucous membrane, however, which is 
most frequently and peculiarly affected, is that belonging to about 
the lower third of the ileum. The whole of the lining membrane of 
the small intestines may indeed participate in the inflammation, and 
here and there spots of lymph may be seen upon its surface, but it 
is in the portion above-mentioned that the principal lesion is found. 
In this part of the canal there is often an increased vascularity over 
the whole of the surface, and in almost all cases irritation seems to 
be most intense in spots which appear, upon closer examination, to 
have been occupied by the small mucous glands of Peyer and Brun- 
ner, so that they are sometimes solitary, and sometimes as it were set 
in clusters. 

The ulceration is generally preceded by some effusion of lymph, 
on the surface of the mucous gland, and, according to Vogel, the 
gland itself becomes the nidus of an interstitial deposit resembling 
scrofulous matter, which he terms typhous deposit (p. 107). This 
matter breaks down, and involving the gland in its disintegration, 
an ulcer is formed by ulcerative absorption, though sometimes there 
may be sloughing of the membrane ; sometimes, too, the peritoneal 
coat becomes involved; the escape of the contents of the canal, and 
consequent peritonitis, are the results. Another consequence of this 
ulceration may be the opening of one or more vessels of some size, 
from which haemorrhage to a considerable extent may ensue. Those 
ulcers are generally accompanied by injection and enlargement of the 
corresponding glands of the mesentery. This ulceration does not 
necessarily continue its process of destruction, since we often find 
the parts where it has been situated in the different stages of repair 
and cicatrisation. 

The symptoms which arise from the above affection of the ileum 
are, deep-seated tenderness about the right iliac fossa, and irritability 
of bowels, the stools being very loose and of a yellow ochry colour ; 
sometimes, however, this complication exists without diarrhoea. The 
pulse is frequent, rather small, and very compressible. The tongue 
is red at the edges with elongated papilla?, the centre generally brown 
and apt to become dry ; sometimes it is glazed. The countenance is 
either pallid or there is a distinct patch of redness on the cheeks, 
which disappears and recurs frequently in the day. The pupils are 
commonly dilated and the eyes bright; besides these symptoms, 



508 CONTINUED FEVEE. 

there is, to use the words of Dr. Addison, "a something in the aspect 
of the patient, and the general character of his symptoms, sufficient 
to apprise the attentive observer with tolerable certainty of the exist- 
ing complication. However mild the case, there is usually a certain 
degree of nervousness, tremulousness, or agitation about the patient, 
sometimes almost amounting to subsultus, and especially manifest on 
attempting to make any exertion ; he is dull and drowsy, with some 
tendency to stupor, but may, nevertheless, always be roused to under- 
stand and answer questions, even during the night, when the mental 
aberration is most considerable." 

The patient may remain in this condition for several days, some- 
times for weeks, and the diarrhoea subsiding, the evacuations become 
more consistent, and he recovers; the convalescence being generally 
slow, and the patient very liable to relapse upon any error in diet, 
exposure, or undue exertion. In other cases, again, the diarrhoea 
continues, the stools are passed involuntarily, the prostration [and 
emaciation increase; there are frequent but irregular exacerbations, 
marked by the presence of the red patch above noticed ; there is 
excessive restlessness, with picking of the nose, lips, or bed-clothes, 
and the patient dies of asthenia; or it may be that before the 
exhaustion proceeds to this extent, perforation of the intestine takes 
place, and he is carried off by peritonitis. 

It is the above form of fever that is peculiarly exposed to the 
additional complications, if so they may be called, of bed-sores, pro- 
duced by continual pressure on one part, from inability of the patient 
to alter his position; the effects of this pressure in arresting the 
nutrition of the part being increased by the generally defective 
nutrition, dependent partly upon the febrile state, and in the present 
case particularly upon the diminished or arrested supply of chyle, 
owing to the obstruction of the lacteals; the sores sometimes com- 
mence in superficial ulcerations, produced by irritation of the faeces 
and urine where the evacuations are passed unconsciously. These 
bed-sores are in themselves a serious evil, being productive of all 
the exhaustion known to be attendant upon the well-known "cellular 
membranous inflammations," and which must tend greatly to aggra- 
vate the exhaustion produced by the fever; besides which they pro- 
long the febrile state, and deprive the patent of sleep by the pain 
and irritation which they occasion. 

Maculce in Fever. — Allusion has already been made to the erup- 
tions in continued fever, and they are deserving of closer observa- 
tion, since, if they do not in their different forms indicate essentially 
different species of fever, they certainly indicate a difference in the 
state of the circulation and of the system generally, which we ought 
never to overlook. There are two forms of maculae upon the dis- 
tinctive characters of which great stress has lately been laid as mark- 
ing different kinds of disease. The former, which we have spoken 
of as the rose-coloured rash, consisting of rose-coloured papillae, dis- 
appearing under pressure of the finger; irregularly scattered over 
the surface of the trunk, generally but few in number, though some- 
times, but very rarely, almost confluent. Each spot continues for 



MACULE IN FEVER. 509 

about four days, but fresh, spots are said to be continually appearing 
to the twenty-first or twenty-second day of the fever; these have 
been described by Dr. Jenner as characterising a specific form of 
fever — the typhoid. 

The other form of rash, which has been supposed to indicate the 
true typhus, consists of mulberry-coloured spots, at first slightly 
elevated, and rendered much fainter, though not entirely disappear- 
ing when moderately pressed upon; but afterwards they assume a 
more livid colour, and are not so much altered by pressure. These 
spots either fade into brownish stains and then vanish, or pass into 
decided petechias or small ecchemoses ; each spot continuing from its 
first appearance to the termination of the disease. The general hue 
of the skin is, during the presence of this rash, rather dusky and 
mottled, constituting what has been termed the sub-cuticular rash.* 

The question of the distinction of typhus and typhoid fever, as 
arising from distinct poisons, and distinguishable by eruption, is one 
that has been some years under discussion; thus Dr. Alison, writing 
at least as early as 1844, states that "An opinion has lately become 
rather prevalent that there are two kinds of fever, to which the 
names of typhus and typhoid fever have been given; of which the 
first, usually unconnected with any affection of the mucous mem- 
brane, is attended with the eruption, and is more contagious; the 
latter is necessarily connected with inflammation, going on to ulcera- 
tion, of the mucous membrane, is unattended with eruption, is more 
protracted and has little contagious property. This term typhoid 
fever is to be regarded as synonymous with gastro-enterite and 
dothen entente. If it be understood that the intestinal inflammation 
in this last case is of specific character, this doctrine can have no 
injurious results; but it is certain that some cases resulting from the 
contagion of the usual spotted typhus, show all the symptoms and 
post-mortem appearances attributed to typhoid fever; and therefore 
it seems probable that the differences observed are only varieties 
depending upon constitution, and on the agency of other causes 
affecting the constitution, besides the existing cause of the disease."f 
The observations of Dr. Jenner are not indeed open to the practical 
objection of regarding any form of fever as synonymous with gastro- 
enteritis; yet it has not been disproved, or rather there is abundant 
evidence to prove, that there is truth in the remark of Dr. Alison, 
respecting the occurrence of theg astro-enteritic symptoms and post- 
mortem appearances, in cases which have undoubtedly been the true 
spotted typhus, both in their origin and in the character of the rash. 

The conclusions which it appears we may most legitimately draw 
from our present information upon this subject is, that in the fevers 
in which the mulberry-coloured and livid spots are present, there is 
a greater tendency than in others to assume the low, sinking form, 

* For a very careful description of these rashes, see Dr. Jenner's paper in the 
thirty-third volume of the Medico-Chirurgical Transactions: Dr. Jenner, however, 
differs from most observers in stating that the mulberry rash totally disappears under 
pressure. 

f Alison's "Pathology and Practice," pp. 44G-7. 



510 CONTINUED FEVER. 

and perhaps a greater liability to head affections, but that never- 
theless there may and frequently does occur severe bowel irritation, 
with inflammation and ulceration of the lower portion of the ileum. 
Where there is the rose coloured rash, on the other hand, there is 
almost always great bowel irritation, and not such early depression 
from the effects of the poison ; but the frequency with which one form 
of the disease has been found to occur side by side with the other in 
many epidemics, though it may not have done so in all, and the 
almost imperceptible differences by which they appear to be distin- 
guished in some instances, seems at present to preclude the belief 
that they are specifically different. 

The Pulse in Fever. — Few of the phenomena of fever are more 
interesting or instructive than the state of the pulse ; and it is by the 
indications which it affords, that we are enabled, more than by any 
other class of symptoms, to regulate our prognosis and our treat- 
ment. One of the effects of the poison being upon the blood, the 
mutual affinity between that fluid and the tissues is weakened, and 
one of the moving powers of the circulation annulled or diminished, 
and consequently we find the heart labouring to overcome the ob- 
structed circulation; but in this instance we have not, in the ordi- 
nary fevers of this climate, the increased tonicity of the arteries 
which exist in inflammation (p. 71), and consequently the pulse is 
sharp and full, but never, except in inflammatory fever, hard. As 
the fever continues, the powers of the system, and consequently the 
contractility of the heart, failing, we have the pulse weaker and 
weaker, and at the same time as soft as at first, or even more so, 
from the diminishing tonicity of the arterial coats. Owing to the 
continued efforts of the heart and the persistent obstruction in the 
capillary circulation, there is not uncommonly a recoil to be felt, 
giving the sensation to the finger of a back stroke (p. 71). Another 
effect of the continuation of the obstruction to the extreme circula- 
tion, conjoined with the continually diminishing power of the heart, 
is, that the latter being unable to empty itself, and therefore con- 
tinually exposed to the presence of its natural stimulus, is inces- 
santly excited to contraction, the effect of which is great frequency 
of the pulse, which is often commensurate with its debility. With 
this stroke of the heart there may also be a tendency to the back 
stroke, and the result will be a kind of struggling or throbbing 
pulse, which is always a sign of imminent danger. 

When there is a subsidence of the fever, whether brought about 
or followed by anything like a critical discharge, or otherwise, — 
though it is to be observed that there is always a return of the secre- 
tions on its subsidence, — the healthy relations between the blood and 
the tissues gradually returning, the obstruction to the current is in 
some measure diminished; and therefore the pulse loses its sharp- 
ness, and the ventricles of the heart being better able to expel their 
blood, it becomes also slower : but the diminished contractility of the 
arteries continuing, with the generally exhausted state of the system, 
the pulse is soft and moderately full : and as the convalescence be- 
comes established, and the secretions abundant, the quantity of the 



DIAGNOSIS AND PROGNOSIS OF FEVER.' 511 

blood in the system being probably diminished, the left ventricle 
empties itself fully, but is slowly refilled. The force of its contrac- 
tion no doubt remains somewhat weakened, but the same is the case 
with the contractility of the arteries, so that they are equally balanced, 
and the result is a slow, very distinct, and nloderately soft and full 
pulse. It may be well here to remark that the conditions of pulse 
which have been here somewhat theoretically referred to the different 
periods of fever, are fully borne out by experience; a quick and 
feeble pulse being that always met with in the advanced stages of 
continued fever, the pulse of convalescence being distinct and slow 
(sometimes below the healthy standard) and moderately soft and full. 

Upon these grounds, but still more upon almost universal experi- 
ence, the frequency of the pulse is of the greatest importance in fever ; 
its not exceeding one hundred is in general a favourable sign, when 
it exceeds one hundred and twenty in adults the danger is great. 

The diagnosis of continued fever is not always so much a matter 
of course as is often supposed, as there are several diseases with which 
it may be confounded, though in the generality of cases it is un- 
doubtedly easy. The mode of the attack, the general oppression, 
with depression rather than excitement of the countenance, the fre- 
quent and compressible pulse, the vividly injected tongue, and in 
many cases the appearance of the eruptions, are sufficient to charac- 
terise the disease at once, not to mention the circumstance of a pre- 
vailing epidemic, or our knowledge of the sources of infection to 
which the patient may have been exposed. 

Cases of difficulty do, however, not very rarely arise, and this dif- 
ficulty results in the majority of instances from some local inflamma- 
tion, generally of a chronic character; such are deep-seated suppura- 
tion, or chronic or subacute disease of the large intestines, mesenteric 
glands, or peritoneum, which will frequently give rise to symptoms 
nearly resembling those of mild continued fever, though upon closer 
observation the fever presents a more remitting character : whilst in 
the aged and persons of feeble constitutions acute inflammations will 
often assume the character of a more severe form of fever. 

Pneumonia, and in its most simple form, may in persons of all 
ages assume the character of severe continued fever, so much so that 
it is only by a careful exploration of the lungs, and not always even 
by this means, that its presence can be detected. And the same 
thing occurs in some cases also of acute diffused tuberculisation of 
the lungs. Puriform infection and poisoned wounds will also induce 
fever of typhoid character. 

Prognosis of Continued Fever. The prognosis of continued fever in 
this country, in persons young and of sound constitution, is in general 
favourable; in very young persons the fever often subsides at the 
end of the eighth clay; in those more advanced in life it is more 
doubtful, and even unfavourable. Persons above sixty are not often 
the subjects of continued fever, but of those which are so the greater 
number do not recover. Dr. Alison states that the mortality in per- 
sons above forty is as high as one in two. It is to be remembered 
also that although fever is most common in the dwellings of the 



512 CONTINUED FEVEE. 

lower orders, and that in such abodes the mortality is the greatest, 
owing to want of ventilation, and often also of proper care and nour-' 
ishment ; yet that when such persons are removed to more favoura- 
ble circumstances, as to the well- ventilated wards of our hospitals, 
they more frequently recover than do those who become the subjects 
of fever among the higher and more educated classes of society : the 
reason of this being probably that there is in the latter case a greater 
excitability of brain, and therefore a greater tendency to subsequent 
exhaustion of the nervous power, or what may be still worse, a 
greater liability to inflammation of the brain or its membranes. 
Another circumstance to be taken into account is the general mor- 
tality in the prevailing epidemic, and more especially as it has 
occurred in the immediate locality. The previous impressions on 
the mind of the patient, again, are not to be overlooked, as it is 
always an unfavourable sign when he has at the commencement of 
the disease expressed a conviction that he shall not recover. For the 
same reason previous mental anxiety, or the having recently under- 
gone losses of friends or fortune, or other severe disappointment, 
have an unfavourable influence. 

As regards the general prognosis, we may also add that it should 
at all times be very guarded, for although mild continued fever very 
rarely proves fatal, still circumstances may arise in its progress which 
no human foresight can foretell or prevent, and therefore though it 
is very'*true in fever, even of the severest form, that " whilst there is 
life there is hope," it is no less true, as is happily expressed by Dr. 
Addison, that " whilst there is fever there is danger." 

In young persons the milder form of this disease will often termi- 
nate favourably in eight or ten days, and in such subjects we may 
look for signs of its subsidence about that time : — namely, a dimin- 
ished frequency of the pulse, a softer and cooler skin with perhaps a 
little moisture upon it, the disappearance of the expression of languor 
and anxiety, a cleaner tongue, and an increased flow of urine, the 
return of sleep, and subsidence of all signs of irritation or disturb- 
ance about the brain. 

In the severe cases, which may be expected to run on for about 
three weeks, a rational prognosis is to be founded upon the considera- 
tion of the sources of danger, and the modes of fatal termination of 
fever ; and the first symptoms of any of the conditions upon which 
they depend are to be regarded as dangerous. 

Modes of fatal termination of Fever. — A most important step to a 
correct prognosis, and sound practice, in fever is, the right apprecia- 
tion of its different modes of fatal termination. The earliest period 
at which fever may prove fatal, is in the stage of oppression from the 
first effects of the poison or morbific agent, upon the system, either 
by its depressing the action of the heart and arteries so as to cause 
death from syncope, or so greatly reducing the powers of the nervous 
matter as to produce fatal coma at the first invasion of the disease ; 
though the cause of this coma may not be made apparent after death 
by the presence of any effusion or perceptible lesion in the brain. 
To the above may perhaps be added early death from the general 



FATAL TERMINATION OF FEVER. 513 

arrest of the extreme circulation, or what we have before spoken of 
as capillary or peripheral syncope. 

These early terminations of fever are however not frequent, in this 
country especially, and consequently the real danger occurs at a more 
advanced period, and arises from more complicated causes. " It ap- 
pears manifestly owing," says Dr. Alison, " to a combination of the 
enfeebled state of the circulation, with peculiar derangement of the 
functions of individual organs, consequent on the attendant inflam- 
mations there. In consequence of this combination, we have three 
distinct fatal terminations of fever which are often blended together, 
but in some cases are quite separate and easily distinguished." 
(1.) The death by coma referable partly to the peculiar action of the 
cause of fever upon the brain, but partly also to increased determina- 
tion of blood thither, or inflammatory action there. (2.) The death 
by asj)hyxia (apnoea), referable partly to the enfeebled state of the 
circulation, and partly to the want of power in the heart to propel 
the blood through the lungs, (and partly also to obstructed capillary 
circulation in these organs as a direct effect of the morbific agent,) 
but partly also to bronchitis and pneumonia. (3.) The death by 
mere asthenia — referable partly to the deleterious effects of the mor- 
bific cause upon the circulation, but frequently also in part to various 
local inflammations prolonging the febrile state, and especially to 
the inflammations and ulcerations of the mucous membranes of the 
intestines, which appear to have in this, as in other cases, a peculiar 
sedative, and what was formerly designated as a sympathetic effect, 
on the heart's action."* 

(1.) As regards death from coma or death from the brain, it is not 
at all common in the commencement of fever, though it may occur 
from the first affect of the poison upon the nervous system. It is 
more common, however, at a more advanced period; and generally, 
in the way of exhaustion coming on as a consequence of nervous 
excitement; and for this reason all symptoms which indicate early 
excitement are far more to be dreaded than those which show a 
sluggishness of the brain. Thus, early delirium, especially if it be 
of an active character, is amongst the worst signs in fever. Intole- 
rance of light is, for the same reason, unfavourable, and therefore a 
contracted pupil, which indicates a highly sensitive condition of the 
retina, is always worse than a moderately full or even dilated one. 
Deafness is not unfavourable, but intolerance of sound decidedly so. 
A persistent delirium is always more likely to be followed by coma 
than where there are intervals of reason, and the delirium is a still 
worse sign when the patient is continually talking upon the same 
subject, especially if that be one in connection with which there is 
reason to believe that his mind may have been powerfully affected. 
Continued sleeplessness is, in the same way, a far worse symptom 
than drowsiness, unless there be reason to apprehend that the latter 
be the result of effusion; in which case, however, it will have been 
generally preceded by active excitement. Indeed, many of the more 

* Alison's " Outlines of Pathology Practice,'' p. 444. 

33 



514 FATAL TEEMINATIOX OF FEVER. 

uneducated of the fever patients in our hospitals seem, as it were, 
almost to sleep through their fevers. Greatly increased heat of the 
scalp, and throbbing of the carotid arteries, are also unfavourable, as 
indeed are also signs of inflammation of the brain or its membranes. 
It is perhaps on this account that there is much truth in the observa- 
tion of Hippocrates, that convulsion occurring in the course of a 
fever is worse than fever supervening upon convulsions. Tremor of 
the limbs and tongue, inability to retain the faeces or urine, picking 
of the bed-clothes, and subsultus tendinum are among the symptoms 
of threatened death from coma. As regards the urine, however, the 
inability to empty the bladder is as likely to be the cause as the 
effect of the cerebral affection. 

(2.) Death from the lungs or death from apnoea may ensue at any 
period of fever, and may take place almost at its onse't from the 
effects of the morbific agent in obstructing the circulation of the 
blood through the capillaries of the lungs. This is not a very com- 
mon occurrence, and belongs to the congestive form of fever when 
very severe. It is threatened when there is early lividity, with a 
very small pulse, and shrunken, livid, cold extremities, with duski- 
ness of the lips and countenance, hurried and oppressed breathing, 
but without pain ; with a skin generally cold, often moist, and scanty 
urine. Such cases, when they do occur, are always very dangerous. 
Death may also ensue in this manner when there is at the same time 
(as in the more advanced stages of the disease) a tendency to fatal 
termination b}^ asthenia, owing to failure in the action of the right 
side of the heart. And on this account the symptoms of pulmonic 
congestion occurring in connection with those of sinking are most 
unfavourable. Death from apnoea may also take place from bron- 
chitis or pneumonia occurring as a complication of the fever; and 
the existence of either of these to any extent increases the danger of 
the latter. Bronchitis often exists in the congestive form, accom- 
panied by sibilant respiration, and with no increase but even a dimi- 
nution in the secretion of the membrane, and therefore unattended 
by any mucous rattles, the pulse becoming feeble, the countenance, 
lips, and extremities congested, and sometimes livid. When the 
latter is the case there is great danger. The same condition may 
also arise from excessive secretion blocking up the tubes and pre- 
venting the aeration of the blood in the lungs, as in the case of 
asthenic bronchitis; and this is perhaps a fatal termination more 
common than that by congestion of the bronchial membrane; and 
for this reason very extensive mucous rattles, especially if pervading 
the small tubes, are unfavourable. This result may arise from pneu- 
monia, the presence of which, therefore, greatly adds to the danger 
of fever. It must also be remembered that fever has a tendency to 
produce inflammation where it has formerly existed, and therefore 
that a previous attack of pneumonia, especially if it have left any 
consolidation or induration of the lung, greatly adds to the danger 
of fever. 

(3.) As regards the death by syncope or asthenia, it is by no means 
a common occurrence in the early stages of fever; still cases are to 



TREATMENT OF CONTINUED FEVER. 515 

be met with in which there appears to be considerable danger from 
the early failure of the moving powers of the circulation ; the signs 
of which are a very feeble and generally very quick pulse, with cold- 
ness and a tendency to liviclity in the extremities; and it is also to 
be borne in mind that, in all periods of fever, death from syncope 
may occur from the neglect of proper precaution against such a 
possibility. 

It is, however, in the more advanced stages of the disease, gene- 
rally after the completion of the second week, that death from the 
more protracted form of syncope, i. e., from asthenia, arising out of 
the combined effect of diminished, or rather arrested nutrition, and 
failing of the heart's action, is to be apprehended. The pulse becomes 
small, weak, and frequent, and very compressible; though in some 
cases, especially in persons advanced in life, it may appear mode- 
rately full, even when there is imminent sinking, owing to the 
obstruction in the extreme circulation and diminished contractility 
of the artery, by which the full impression of the systole, feeble 
though it may be, is conveyed to the ringer. There may be failure 
of the extreme circulation, the temperature of the surface failing, the 
skin becoming covered with a clammy sweat, and the extremities 
becoming cold and shrunken. It has also been stated that feebleness 
in the ventricular systole, by which the first sound of the heart 
becomes less distinct than the second, is another sign of threat- 
ened death from asthenia. With the above symptoms there is also 
a dry, black, and chapped tongue, coated with black sordes, and 
similar incrustations upon the gums and teeth. The delirium char- 
acteristic of this condition is of the low muttering character, arising, 
as it were, from failure in the cerebral circulation, and consequently 
indicating a state of things different from that which gives rise to 
the active delirium of inflammation or excitement of the brain, and 
from the coma which belongs to nervous exhaustion. The eruption, 
when there is any, will • often show signs of tendency to asthenia by 
assuming a livid colour; and another unfavourable symptom is the 
appearance of livid petechias or vibices, to which too there will often 
be added another unfavourable sign, namely, the passage of a large 
quantity of black blood by stool or urine. The patient at the same 
time sinks gradually to the bottom of the bed, and the stools and 
urine pass involuntarily. The pulse is no longer perceptible at the 
wrist, and the heart's action becomes more and more feeble till it 
ceases altogether. 

The treatment of Continued Fever. — We believe that it will be found 
that the treatment of all forms of continued fever must be based upon 
the same principles, and therefore that there is more danger than 
advantage in dividing this disease into endless varieties, and appor- 
tioning to each its peculiar mode of treatment; since it will generally 
be found that the treatment most applicable to each will be best 
arrived at by the application of those general principles which have 
been established by an induction including all. 

Absolutely ignorant as we are of the proximate cause of continued 
fever, we may nevertheless venture to affirm that there is no class of 



516 TREATMENT OF FIRST STAGE. 

diseases in which science has done more towards their successful 
management ; for by a systematised knowledge we become acquainted 
with the provisions of nature, by which the action of the morbific 
agent is rendered transient ; and thence we are taught to look for its 
subsidence after a definite time; and consequently, to expect the 
recovery of the patient, provided that the functions necessary for the 
continuance of life can be maintained until that time, and also that 
no serious lesion is inflicted upon any vital organ. In the same 
manner, too, we become acquainted with the different modes in 
which fever may be fatal, and thus we are enabled in some degree 
to anticipate and guard against such terminations; or, in the words 
of Cullen, to "obviate the tendency to death," and also to subdue, 
where we cannot prevent, those local complications which may either 
be fatal by interfering with the functions of a vital organ, or, by pro- 
longing the febrile state, interfere with and obstruct the natural ten- 
dency to recovery. 

It may here be asked — Is it possible to cut short the fever in its 
onset? We know that various remedies have been recommended, 
and are still frequently employed for this purpose, and that not 
without apparent success ; but we know also that such measures are 
often applied, and that very early, without such a result ; and further, 
that ephemeral fever is apt to occur under circumstances in which 
the continued fever might be apprehended, so that we see that the 
evidence in favour of the frequent success of remedies applied with 
this intention, rests upon rather slender grounds. At the same time, 
we ought to state that the means generally employed are a moderate 
bleeding, followed by a combination of a purgative with an emetic ; as 
a dose of tartar emetic followed by rhubarb and calomel, or a cathar- 
tic draught; and sometimes the tartar emetic, by first exciting per- 
spiration, and afterwards acting upon the bowels, will be of itself 
sufficient for the purpose. It should be remembered, however, that 
bleeding is rarely a safe proceeding at the commencement or at any 
other period of fever, and that the same remark may apply in some 
cases to the tartarised antimony, as well as to active purgatives. As 
a general rule, however, when there is no great tendency to diar- 
rhoea, and the patient is seen early in the disease, the latter remedies 
may be used with advantage, in a moderate degree; since, although 
they will not often cut short the disease, yet such evacuations tend 
rather to improve its subsequent progress, provided always that 
there be not already any signs of exhaustion — for instance, by 
administering an emetic of ipecacuanha with a small quantity of the 
tartarised antimony ; and when the bowels are not freely acted upon, 
four grains of hydr. cum cret., and four hours afterwards two or three 
drachms of castor oil. 

Another means by which the fever may sometimes be arrested at 
its commencement is cold effusion ; that is, pouring cold water over 
the whole surface, and then speedily drying the patient. After this 
has been done, it will not rarely happen that the surface becomes 
bedewed with a moderate perspiration, the patient falls into a sleep, 
and awakes with the skin cooler, and the fever much abated. This 



FEVER — BLEEDING. 517 

is a practice, however, which, can only be pursued soon after the 
febrile reaction has set in, when the surface, including the extremi- 
ties, is rather above than below the natural temperature, and the 
pulse moderately firm : for if it be applied after the fever has con- 
tinued for some days, or when there is any tendency to coldness of 
the extremities, or the pulse is compressible (conditions which apply 
to the greater number of cases when first seen by the medical prac- 
titioner) we might incur the risk of dangerous or even fatal syncope, 
or at all events, aggravate the tendency to internal congestions leading 
to some of those inflammatory complications which are amongst the 
chief dangers- in fever. 

Among the means of subduing febrile action which most readily 
suggest themselves is the abstraction of blood: but of this it cannot 
be said that it renders the subsequent progress of the fever more 
favourable ; on the contrary, in the great majority of fevers in this 
country, it enhances the risk of subsequent death from asthenia, 
which is, perhaps, the greatest to be apprehended from uncom- 
plicated fever ; and therefore, although it may be saying too much 
to affirm that in no case ought blood to be taken from the arm in a 
case of fever, simply as such, yet it is far more safe to regard such 
a practice as an exception from the general rule. When indeed the 
pulse is full and frequent, and not compressible, provided also this 
fulness is real ; with a hot skin, a ferrety eye, or other signs of cere- 
bral excitement, blood may be drawn, the patient being placed in an 
erect or sitting posture, and the vein closed upon the first signs of 
syncope. The quantity of blood which flows will be the sign of the 
propriety of the operation having been performed, and also of the 
tendency to any inflammatory complication. It is not here meant 
to deny that cases such as have just been described do not occur 
ever in this climate, but that cases are not ' to be assumed as such 
simply because they are fever, and because the febrile excitement is 
considerable. 

Blood-letting, too, when applicable in fever (simply as such), is so 
only at the commencement of the febrile reaction, and in the greater 
number of cases the practitioner is not called in till this has existed 
some days ; and then, unless there be some very urgent symptoms 
indicating its performance, the question of general bleeding is not to 
be entertained : nor indeed is the abstraction of blood in any way, 
simply with a view to moderating the course of the fever : though 
local depletion, either by leeches or cupping, may be adopted with 
advantage, with a view either to obviate the tendency to one of the 
modes of fatal termination which there may be reason to apprehend, 
or to relieve any particular organ which may appear to be specially 
affected. 

In the mean time those measures only must be adopted which will 
safely diminish the febrile action. Of these the first is what has 
been termed the antiphlogistic regimen, or placing the patient upon 
such a plan as regards both diet and external circumstances as shall 
the most effectually preclude all excitement of the nervous and vas- 
cular systems ; though even at this period, of the disease we must 



518 ANTIPHLOGISTIC REGIMEN. 

not lose sight of the principle, that we are endeavouring to avoid 
such excitement as much on account of the exhaustion by which it 
is generally followed, as from the immediate ill effects to be appre- 
hended from the excitement itself. 

The first thing then to be done is to prohibit all muscular exer- 
tion, and with this view the patient must be strictly confined to bed ; 
all stimuli to the senses and to the feelings and intellect must be 
withdrawn. The room should therefore be darkened, or a very 
moderate degree of light admitted. Sound should be excluded 
where it can be done ; all conversation and reading, and the access 
of more persons than absolutely necessary, forbidden. It is especi- 
ally desirable that all persons about the patient, whether medical 
attendant, friends, or nurses, should maintain a cheerful though quiet 
deportment. 

The diet at this time should be of the most unstimulating kind ; 
milk and water, or thin barley water, with an occasional cup of tea, 
will generally be sufficient, as long as the febrile excitement is great. 
The temperature of the room should be moderate — about sixty in 
summer, ancl from fifty to fifty-five in winter, and there should be as 
free a circulation of air as is 'consistent with the comfort of the 
patient. The advantage arising from this is, that the accumulation 
about the patient of noxious effluvia from his own person may be 
thus obviated, and the poison in the system more quickly eliminated. 
There is, however, some difference of opinion upon this point. Dr. 
Alison observes, that the "disease frequently runs its course quite 
favourably in very foul and close air," and it certainly often appears 
when a patient has lain in a warm and close room during a considerable 
part of the disease that the change to cool and fresh air (particularly 
if accompanied with some muscular exertion) has an injurious effect, 
chiefly in bringing on a complication of inflammation. ISTow that 
many patients do well under the unfavourable circumstances of foul 
air and close apartments cannot be denied, but it will be found 
equally true that the rate of mortality is increased ; and as regards 
the advantages of pure air, it has certainly appeared in many cases 
brought to Gruy's hospital from some of the worst houses in London, 
that the change to a purer air has of itself a beneficial effect upon 
the progress of the disease; and even in certain beds, which are the 
best placed for ventilation, the cases of fever are generally found to 
run their course most favourably. And certainly the cases do better 
when removed to one of the large general hospitals than when taken 
to the fever hospital ; where, notwithstanding the most scientific ap- 
plication of every means of obviating it, there is a greater accumula- 
tion or concentration of the poison than in the general hospitals where 
the patients are mixed almost indiscriminately, care only being taken 
not to allow a larger proportion than about ten per cent, of fevers in 
large and airy wards. All this, however, does not impugn the cor- 
rectness of the remark of Dr. Alison just quoted, which shows the 
necessity for caution in effecting a removal. 

Another important precaution, for such it is to be regarded, rather 
than a direct curative measure, is the regulation of the bowels. We 






TEE AT ME NT OF FEVER. 519 

know that in many cases the greatest danger to be apprehended 
arises from irritability of bowels, and therefore all stimulating and 
drastic purgatives must be avoided ; but the accumulation of morbid 
and decomposing fascal matter in the intestines being likely in itself 
to prove a source of irritation, it is necessary when there is not a mode- 
rate evacuation at least once in twenty-four hours, to relieve them 
by the hydr. cum cret. followed by castor-oil, as before recommended. 

When the above precautions are observed, the greater number of 
cases, in persons of sound constitution, will generally recover spon- 
taneously; the fever often, beginning to subside in young subjects 
as soon as the eighth or tenth day ; though in adults it will generally 
run on to the fourteenth or twenty -first. In these favourable cases 
active treatment cannot be too strongly deprecated, but there is one 
class of remedies which have long been in use in the treatment of 
fevers, though it is perhaps only of late years that their virtue 
has been fully appreciated ; and these are, what have been termed 
salines ; that is to say solutions of the neutral salts or alkaline 
carbonates. They have generally been regarded as simple diapho- 
retics and diuretics, but they also tend to obviate that liability 
to capillary obstruction which is among the earliest effects of the 
morbific agent. It is possibly to their action upon the extreme cir- 
culation, that their effect upon the secretions is mainly to be at- 
tributed. The liq. ammon. acet., or the citrate of potass, which may 
be given either in the state of effervescence, or after that has sub- 
sided, are very useful and convenient salines ; but they must be 
avoided when there is reason to apprehend bowel irritation ; in such 
cases the bicarbonate of soda is to be preferred. 

When then we are called to a case of fever, some days, as most 
commonly happens, after the reaction has been fully established ; 
after having satisfied ourselves that the disease is fever, and not one 
which may by possibility be mistaken for it ; our first duty is to 
inquire into its probable origin, and having done this to examine 
carefully as to the presence of maculce, and all other symptoms which 
might give a distinctive character to the disease (particularly in 
reference to any prevailing epidemic). Our next object must be to 
ascertain, as nearly as possible, the age of the fever. We should 
then proceed to search, as far as the condition of the patient allows, 
for any of the lesions liable to complicate the fever, and if none of 
these be found, we should direct our attention particularly to the 
bowels, and to the brain. If there have been no evacuation within 
the last twenty -four hours, we should direct the hydr. cum cret. 
to be administered, followed by the castor-oil ; if, however, there 
have been no alvine evacuation for a longer period, or if the medi- 
cine above recommended should fail in producing one, we should 
have recourse either to an enema, consisting of an ounce of castor- 
oil in a pint of gruel, or to a common soap injection. These means 
will rarely fail, though in some forms of fever, where there is con- 
siderable head affection, the bowels will be very obstinate, in which 
case a full dose of calomel may be given, followed by more castor- 
oil, and, if necessary, a cathartic enema may be afterwards adniinis- 



520 TREATMENT OF FEVER. 

tered. This practice, however, belongs more to fever complicated 
with inflammation within the cranium ; and as a general rule drastic 
purgatives should be carefully avoided. 

It may happen, on the other hand, that the bowels very early 
become irritable. When this is the case, and it appears that the 
quantity passed has been small, and if there are pieces of solid matter 
in the evacuations, we may at first give two grains (not more) of 
hydr. cum cret. and one ' or two drachms of castor-oil two or three 
hours afterwards, though it is not desirable that these medicines 
should produce more than two or three pretty free motions. After 
this, as also when we have good reason for believing that the bowels 
have been sufficiently emptied at the commencement, we must at 
once have recourse to means for checking the diarrhoea ; the pulv. 
cretse co. of the Pharmacopoeia, in doses of about ten grains, will 
often answer this purpose ; or it may be given with about a drachm 
of tincture of catechu in cinnamon water : or the mist. Cretan in doses 
of about half an ounce may be employed, with or without about 
fifteen grains of the aromatic confection ; though when there is much 
tenderness of the epigastrium, or the tongue is red. it is better to 
omit the latter. A very useful means of checking diarrhoea is an 
enema consisting of about three ounces of starch (decoct, amyli of 
the Pharmacopoeia), and one ounce of syrup of poppies, or what 
answers nearly as well, about half a drachm of tincture of opium. 

The head also demands careful attention, and, even although there 
may be no particular cerebral complication, we often have delirium 
about the middle period of the fever, or even earlier. Where this 
delirium is active, and the pulse at all sharp, and the pupils con- 
tracted, and if there be also considerable heat of the scalp, and throb- 
bing of the carotids, a few leeches (i. e. from four to eight) may be 
applied to the temples ; but we must be careful that the above con- 
ditions exist, as if this step be taken when the pulse is compressible, 
or the pupils rather dilated, as is the case in the delirium which 
attends the gastric irritation, we shall increase rather than diminish 
the danger of our patient. The shaving of the scalp will always be 
attended with relief, where there is any tendency to delirium with 
increased heat about the head.. 

When the excitement or delirium continues, we should apply a 
cold embrocation to the shaven scalp, provided the heat be consider- 
able. A convenient application is one part of rectified spirit with 
five of water ; or a better may be prepared by mixing one part of 
spirit with two of water, and two of vinegar ; or two parts of liq. 
amnion, acetat. with one of dilute spirit. There is often much harm 
done from the slovenly way in which cold is applied to the head ; if 
it be done by means of a piece of linen soaked in the lotion, this 
should be frequently repeated so long as the head remains hot, for if 
this be neglected there is a reaction as soon as the linen becomes 
dry, or nearly so, and thus the determination to the head is increased. 
On the other hand, it should be remembered that cold applied in this 
way is a sedative of considerable efficacy, and that if it be persisted 
in after the head and face have got at all below the natural tempera- 



TREATMENT OF FEVER. 521 

ture, there may be a risk incurred of injuriously depressing the 
moving powers of the circulation. 

The state of the respiratory organs must at the same time be care- 
fully watched ; but here, except in cases of complication with actual 
inflammation of some of the thoracic viscera, there will rarely be 
occasion for active interference. In all cases of fever which are 
severe, there is more or less dyspnoea ; and it will often be found, 
upon examination of the chest, that there are pretty extensive sibilus 
and ronchus, showing congestion and turgescence of the mucous 
membrane both of the small and large tubes ; this, however, is not to 
be mistaken for active bronchitis, or to be treated as if it were such ; 
the congestion being but the result of that general tendency to 
obstruction in the extreme circulation, which is one of the effects of 
the morbific agent. A small quantity of ipecacuanha in one of the 
saline mixtures already mentioned, may be given with advantage in 
such cases ; provided the bowels are not very irritable ; if they are 
so, the ipecac, may be added to the soda draught, or given with a 
little cretaceous mixture. A small quantity, as one grain, of hydr. 
cum cret., may also be given, with about three grains of ext. hyoscy- 
amus night and morning. If the irritation of the bronchial mem- 
branes continues after the skin becomes soft or moist, a blister applied 
over the sternum will often afford much relief. 

If none of the complications incident to fever make their appear- 
ance, we must carefully watch for symptoms indicating the approach 
of any of the fatal terminations. Now, the death by coma as well as 
the death by apnoea belong more to those cases in which there is 
inflammatory complication of the brain or lungs, and the appropriate 
treatment will be further considered in speaking of that belonging to 
such complications ; it should, however, be borne in mind, that either 
of these modes of dying may occur as a direct effect of the morbific 
agent. In the former case this may be by its effect upon the brain ; 
under such circumstances, our remedies must be much less active 
than when the same termination is threatened from active inflamma- 
tion of that organ ; and it should be remembered also, that mere 
stupor from which the patient can be roused, requires but little 
treatment ; and the same thing is applicable to an obtuseness of the 
senses of hearing and sight, such torpidity of the brain being in 
general a favourable symptom. Whereas, increased mental excita- 
bility or increased susceptibility of the above senses indicate an 
excitement which is liable to be followed by a corresponding exhaus- 
tion of the nervous power, ending in death by coma. 

In the case of mere stupor but little treatment is required : the 
head should be kept cool, and when necessary the cold lotion applied ; 
and if the bowels are sluggish, they should be stimulated by mode- 
rate purgatives, as the combination of rhubarb and calomel, or where 
they appear obstinate, five grains of the latter may be administered, 
and followed, in three or four hours, by half an ounce of castor-oil. 
When, as is sometimes the case, the inaction of the bowels is chietly 
owing to the indolence or drowsiness of the patient, a common enema 
of gruel and salt, to which may be added an ounce of castor-oil. 



522 USE OF OPIUM IN FEVER. 

should be administered ; or where the bowel requires more active 
stimulation, it may be composed of about twelve ounces of compound 
infusion of senna with a drachm of powdered jalap. In some cases 
of cerebral oppression with torpid bowels, a full dose of calomel, to 
the extent even of fifteen or twenty grains, affords great relief ; but 
it must only be employed when there is no tenderness of the abdo- 
men or redness of the tongue, and where the motions which have 
been passed have been entirely solid and without mucus. In these, 
as in almost all cases of cerebral oppression, diuretics will be found 
useful, especially in the form of salinas ; indeed, the remedies just 
recommended need not interfere with the continuance of the saline 
treatment. Thus, the spirit of nitric aether may be added to either 
of the saline draughts ; or it may be given with from five to ten 
grains of nitrate of potass. 

In other cases, again, we have to dread death by coma, from 
exhaustion of the nervous power consequent upon continued excite- 
ment. In such cases it is that the mode of death is not altogether 
unlike simple asthenia or gradual syncope, taking place simultane- 
ously with cerebral oppression; though the symptoms referable to 
the brain are the most conspicuous and embarrassing, as well as 
those to which our treatment should be mainly directed. Here it is 
most important to allay the excitement, which may often depend 
upon the direct effect of the poison upon the brain, and appears to be 
the immediate effect of a state of that organ widely different from 
inflammation, but which may sometimes be associated with a ten- 
dency to that condition. 

When the head is hot and the pulse sharp, a few leeches may be 
applied to the temples ; but it will rarely be expedient to go further 
in the way of depletion. The head, too, should be shaved, and the 
cold lotion applied according to the cautions already given. The 
bowels must also be attended to, and sufficient evacuations procured, 
if necessary, by moderate purgatives ; though sometimes the chalk- 
mixture, or the starch and poppy clyster, may be required. Here, 
also, as in all cases of fever, the bladder must be carefully attended to. 
The best remedy, perhaps, for this condition of the nervous system 
(as long as the . febrile excitement is considerable), is the henbane, 
which may be given where there is no tendency to diarrhoea, in com- 
bination with hydr. cum. cret., or a little camphor may be added 
(F. 92).* When there is much tremor, and the excitement increases 
at night, we may withhold the henbane during the day, but continu- 
ing the saline, try the effect of a full dose of the former at night. If, 
as commonly happens, the restlessness continues, the question arises 
as to the procuring rest by means of a full dose of opium. This is 
one of the nicest points in the practice of physic, as the misapplica- 
tion of this drug under such circumstances is an error almost fatal, 
frequently altogether so. Opium must not be given when the heat 

* (92) R. Hydr. cum. Tret. gr. iss. 
Camphorge rasse, gr. ij. 
Ext. Hyoscy. gr. iij. Misce. 
Ft. Pil. i. 



TREATMENT OF FEVER — APNCEA. 52 



9 



of the scalp is considerable or the skin dry, or the urine scanty and 
loaded, or the pulse sharp, or the delirium violent; and above all, 
when the pupil is contracted. When, however, the heat of the surface 
has been subdued, and the skin softened or rendered moist by the 
saline and other treatment just recommended — when the secretion of 
urine has been increased, the pulse softened, the tongue moistened, 
and the delirium has become more of a talkative, incoherent character, 
but without violence, and, which is indispensable in the administration 
of opium, if the pupils have become dilated, or even moderately full, 
we may, after several nights of restlessness, hope for refreshing sleep 
from a full dose of this drug or some one of its preparations. A con- 
venient form will be from half a grain to a grain of hydrochlorate or 
acetate of morphia (perhaps the former is to be preferred); of this 
half a grain may be given at night, and should the restlessness con- 
tinue without contraction of the pupil, it may be repeated after two 
or three hours. When the first dose does not produce the desired 
effect, or where the skin and tongue are moist, the urine abundant, 
and there are other reasons, either from the appearance and condi- 
tion of the patient, or from previous history, to believe that he has 
considerable tolerance of opiates, we may increase the dose, giving 
as much as one grain of the hydrochlorate, or its equivalent, one 
drachm of the liquor. Blistering the nape .of the neck may also be 
of service in such cases ; but it must not be done till the febrile heat 
has subsided, and the activity of the symptoms been in some measure 
subdued ; nor in cases where there are livid macuke, with much 
depression and venous congestion, as there might be danger of 
sloughing. Upon the whole, it is a remedy more applicable to the 
case of stupor than of excitement. The use of wine is an important 
consideration in this condition of fever; the mere presence of deli- 
rium is not to be regarded as in any way contra-indicating it, if the 
pulse is compressed and feeble, and the pupils not contracted; where, 
in fact, we have the symptoms of nervous excitement, with little 
power and no symptom, of inflammation of the brain or its mem- 
branes, it may be as useful in preventing death by coma as that by 
asthenia. 

It may, perhaps, be thought that the doctrine to which we have 
throughout 'given a somewhat prominent position, namely — that the 
morbific agent in fever acts mainly upon the blood, and destroys its 
natural affinity for the tissues with which it is brought in contact in 
the course of the extreme circulation — is an opinion rather than an 
established law; but whether this be so or not, we believe that it is a 
fact, that in fever there is this loss, on the part of the blood, of its 
natural affinities, which causes delay in the capillary circulation ; and 
that this fact is independent of any opinions we may hold as to the 
blood being so affected ; or as to its being secondarily influenced 
through the action of the poison upon the nervous system. This 
effect of the disease upon the extreme circulation often shows itself 
very formidably in the pulmonic circulation, threatening death from 
apnoea; the lividity and venous congestion, with diminution of the 
arterial pulse, in some cases of this kind are very remarkable, 



524 APNCEA — ASTHENIA. 

though death from this cause, independently of actual lesion of the 
lungs themselves, is not common, and in their treatment it will be 
important not to mistake the sibilant respiration intermixed with 
ronchus, which may generally be heard (as the effect of the engorge- 
ment of the bronchial membrane) for acute bronchitis. In general, 
cases of this kind require little active treatment : a saline draught, 
consisting either of the citrate of potass draught, or that with liquor 
amnion, acet., with the the addition of about ten minims of ipecacu- 
anha wine, or from fifteen to twenty of wine of potasso-tartrate of 
antimony, will generally have considerable effect upon this state of 
the circulation; which will be aided by a moderate use of mercury, 
where it is not contra-indicated by irritability of bowels ; for this pur- 
pose from one to two grains of hydr. cum cret. may be given, with 
three of conium or hyoscyamus: when the skin has become some- 
what moistened, a blister applied to the chest will promote the 
restoration of the pulmonic circulation. 

Death from asthenia or from gradual syncope is perhaps the most 
frequent of the fatal terminations of fever, and in some epidemics it 
is one against which we must be prepared from the very commence- 
ment. On this account the pulse must be carefully watched, and as 
long as it remains sharp, and the skin hot and dry, and the urine 
scanty, the use of tonics and stimulants must be abstained from. 
But even in this condition of the patient beef-tea may be allowed if 
it do not, as is sometimes the case, irritate the bowels. The best 
form where the stomach and bowels are irritable is Liebig's creatine 
soup. When the pulse becomes more compressible, especially if the 
tongue begins to soften at the edges, we may, if there be increasing 
signs of prostration, administer a little diffusible stimulant; of this, 
that which may generally be employed with the greatest safety is the 
sesquicarbonate of ammonia, which will at first be best combined with 
the solution of acetate of ammonia, as we thus gain the aid of a saline 
in promoting the passage of the blood through the capillaries : indeed it 
is often syncope or asthenia commencing in the extreme vessels (what 
we have ventured to term peripheral syncope) that we have to con- 
tend with; and consequently, although we may by stimulants main- 
tain for a time the action of the heart, we can do but little towards 
overcoming the obstruction that embarrassed it, so long as the cause 
of that obstruction continues. On this account we must persevere 
with the salines whilst the pulse retains any sharpness, or the back 
stroke already noticed. A convenient form for the combination of 
these remedies is the following (F. 93).* 

The next point to determine, and it is one of no small difficulty 
and of extreme practical importance, is the administration of wine. 
Now as wine is a direct stimulant to the heart and large vessels, and 
has but little influence over the extreme circulation except through 

* (93) R. Ammon. Sesquicarb. gr. iv. 
Liq. Ammon. Acet. g ii. 
Tinct. Serpentarire, gj. 
Infus. Serpentar. 5 j. Misce. 
Ft. Haust. ; to be taken three times, or oftener, during tlie day. 



CHEST AFFECTION. 525 

the heart, it is certainly highly desirable to delay its use until the ten- 
dency to capillary obstruction has passed away ; or, in other words, un- 
til the fever itself has subsided, which will generally be shown by the 
pulse becoming slower and fuller, but at the same time soft and very 
compressible. When this is the case, although the tongue may be 
brown, the patient almost unconscious, andin the most abject state of 
prostration, we may confidently expect the greatest benefit from wine 
freely administered. It is not always that the indications for its use 
are so clear, as in the worst cases we often find the central moving 
powers of the circulation to be sinking, whilst the febrile state and 
the consequent difficulty of the extreme circulation continue : under 
these perplexing circumstances, we must be guided by other con- 
ditions as well as by the pulse. Thus, in cases where wine is most 
required, the patient generally lies prostrate upon his back and sink- 
ing lower and lower in his bed, the countenance is sunken, the eyes 
hollow, and the surface is inclined to cold at the extremities, though 
it may be hot about the trunk. If, however, this heat is attended 
with dampness, we may with more confidence administer wine. The 
state of the pupils will often aid us, for in general, stimulants are 
better borne with a full than a contracted pupil. The tongue in 
such cases will generally be brown from a crust of sordes, which also 
covers the teeth and gums. The state of pulse which affords the 
most certain indication for the use of wine has just been described, 
but as in the worst forms of fever we must not wait for that which 
may never show itself, we must consider feebleness and compressi- 
bility as themselves indications for the use of wine, provided the 
other signs of prostration are likewise present. 

A rule has been proposed by Dr. Stokes which is certainly worth 
attending to, though it may not be at all times applicable; namely, 
that when the first sound of the heart is nearly lost and becomes 
much more feeble than the second, wine is indicated. It will not be 
safe in all cases to wait for this symptom, but certainly where it does 
occur, it is in general a sign that stimulants are required. As regards 
the quantity of wine to be given, it is impossible to lay down definite 
rules, as it must be given according to its effects rather than by mea- 
sure. Where the signs of sinking are not very urgent we may begin 
with an ounce of sound port or sherry, which may be diluted with 
an equal quantity of water, and given about four times in the twenty- 
four hours, or even a less quantity may be given at shorter intervals. 
It will always be necessary to watch most carefully the effect of the 
wine, and if it cause increased heat of the head or active delirium, or 
if the tongue become drier under its use, or the pulse more frequent 
and sharper, without any increase of volume, it must be withdrawn : 
but, if the tongue become moister or the pulse less frequent or fuller, 
and especially if the patient should get some sleep or appear more 
tranquil, even though the depression become more alarming, its use 
must be continued and the quantity increased, and this must be done 
without limit as long as the prostration continues, or the pulse appears 
to become more feeble. Sometimes ten, twelve, or more ounces must 
be given in the day, and in cases of extreme prostration, brandy and 



526 COMPLICATED FEVER — HEAD AFFECTION. 

also ether must be given in addition; but such are almost despe- 
rate cases, though certainly where there has been a slow and com- 
pressible pulse, patients have sometimes been saved by the timely 
administration of the strongest stimulants. 

Complicated Fever. — The treatment of fever complicated with 
inflammation of the brain or its membranes is a matter of great 
nicety, owing to the difficulty of ascertaining with certainty how 
much of the cerebral disturbance is owing to inflammation, and how 
much to the direct action of the morbific agent upon the brain. 
Where the symptoms plainly indicate that the former is the case, 
we must employ measures adapted to subdue that inflammation; 
though even here we must remember that depletion is not borne as 
in simple inflammation of these organs. In doubtful cases the head 
should be shaved and cold applied to the scalp, according to the 
directions already given. The next question will be the use of 
depletion ; and here we must be guided by the sharpness and hard- 
ness of the pulse, by the state of the secretions (the bowels being 
almost always very difficult to act upon in cerebral inflammation, 
though rarely so in fever ; urine also being scanty in the former 
case), by the tongue, which is more inclined to be white the more 
the disease (in the early stages) assumes the character of inflamma- 
tion. We may also remark that when inflammation of the encephalon 
occurs in the course of mild continued fever, it has more of the char- 
acter of common inflammation, and therefore is more amenable to 
antiphlogistic measures, and more tolerant of them, than when it 
occurs almost at the first commencement of scarlet fever. In the 
former case blood may be drawn from the arm if the pulse will warrant 
it, and the patient may be cupped behind the ears or at the back of 
the neck, after an interval of twelve or twenty -four hours, and if there 
be no great heat of skin a blister may be applied. In the latter case 
it is rare that bleeding in any shape is admissible, especially if there 
be any eruption. The bowels must be freely opened by moderate 
doses of calomel, the action of which may be aided, if necessary, by 
a senna draught, and the calomel may be afterwards continued in 
doses of about two grains every four hours until some of its specific 
effects are produced; or if the bowels should be irritable mercurial 
inunction may be employed, or the blister may be dressed with mer- 
curial ointment. In whatever form, and at whatever period of the 
fever, the signs of inflammation of the encephalon, provided they 
really are such, show themselves, opium is inadmissible; useful 
though it is in cases of nervous excitability without inflammation; 
the great guide, in this matter is the pupil. A most important part 
of the treatment here, as in all cases, is obviating all excitement, and 
as much as possible all use of the organs suffering from inflammation, 
or threatened with it; and therefore light must be excluded, and the 
room kept as quiet as possible, and every cause of mental excitement 
guarded against: and forcible constraint must only be resorted to 
when necessary to prevent the patient inflicting an injury upon him- 
self or others. 

In fever complicated with chest affection the same principles of 



USE OF WINE IN FEVEE. 527 

treatment must be pursued. When we have evidence that the dis- 
ease really is fever, and where there is no reason for supposing the 
inflammation in the thorax to be a mere coincidence — as, for instance, 
the effect of exposure to any exciting cause of such inflammation 
after or shortly before the invasion of the fever — we are justified in 
believing that the local disease is the effect of the morbific agent 
upon that particular organ, and may consider it, much in the light 
of a specific inflammation, amenable to laws somewhat different from 
those by which common inflammation is regulated, and less tolerant 
of the antiphlogistic treatment applicable to the latter. In this case, 
too, we may reasonably expect that, if the local disease do not 
entirely subside, it will be very much mitigated when the general 
fever comes to an end. If, on the other hand, we have reason for 
believing that the local disease is the effect of some cause inde- 
pendent of the fever, we cannot entertain the same expectation of 
its spontaneous subsidence, and are therefore called upon to use more 
active measures for its suppression, and calculate upon a greater 
amount of tolerance of them. But it may be urged that the physical 
signs in both cases are the same, and in both we have the general 
symptoms of fever. The way to escape from this difficulty is to 
remember that it is the whole condition of the patient that we have 
to deal with, and not only the bronchitis, or pneumonia, or other 
local inflammation ; and therefore we must be guided as to the use 
of depletory, and other antiphlogistic measures by the probability of 
their tolerance, as evinced by the greater or less degree of prostration, 
by the tongue, and, above all, by the pulse; and where these, espe- 
cially the latter, do not indicate a toleration of depletion, we are not 
justified in having recourse to it on account of the inflammation, 
whatever reason we may have for supposing that it arises from ordi- 
nary rather than specific causes. 

Of the broncial congestion, threatening death by apnoea, and of 
the inexpediency of treating it as acute bronchitis, we have already 
spoken. Where, indeed, there are rattles as well as the wheezing, 
and the skin is hot and the pulse sharp, if the tongue be furred as. 
well as red at the edges, the saline, with the addition of antimonial 
or ipecacuanha wine may be administered (the latter is to be pre- 
ferred if the bowels are irritable), and the mercurial with henbane 
may be given as before recommended. When the dyspnoea is urgent, 
with pain referred to the sternum, and the pulse is such as to justify 
it, blood may be taken by the application of a few leeches over the 
sternum, or, what is better, by cupping. Cases may indeed arise that 
require general bleeding, but they are exceedingly uncommon. 
When, as it is apt to do (more especially if depletion have been 
unadvisedly used), the bronchitis assumes the asthenic and suffoca- 
tive form already described (p. 98), it must be treated accordingly, 
and with even a greater amount of stimulants and support, than 
simple bronchitis. 

In many cases of fever we have pneumonia occurring as a compli- 
cation; and often in a form likely to escape detection, unless the 
chest be carefully examined. >sow the importance of the discovery 



528 COMPLICATED FEVEE. 

consists more in its forewarning us of the mode of death (that by 
apnoea which is most to be apprehended, than in suggesting any 
active measures for the subduing of the inflammation. — We are not, 
of course, here speaking of the diagnosis between primary pneu- 
monia and typhus fever, which has been already explained. — When 
the primary disease is fever, and the pneumonia occurs in its pro- 
gress, it is probably owing to the effect of the morbific agent upon 
the lung itself; and when consolidation is the result, the deposit pro- 
ducing it may be of a nature analogous to that spoken of as the 
typhous deposit, occurring in the intestinal glands, and therefore not 
of a character to be improved by depletion: but, whether this be so 
or not, we must be guided in the use of remedies by the condition of 
the patient, and not he led to employ venesection because there is pneu- 
monia, unless there is evidence, from the pulse and other symptoms, 
of its probable tolerance. If the pulse be such as to justify the 
depletion, which it rarely is, we may hope, by the use of bleeding or 
cupping, either to put an end to the inflammation, or so far to arrest 
its progress as to allow time for the employment of the means already 
recommended for the treatment of that disease ; but whilst this is 
admitted, the caution is again repeated, that the great danger lies in 
being hurried to the use of venesection through anxiety to save the 
patient from so formidable a complication of the fever : and a belief 
is expressed, which increased experience tends to confirm — that the 
inflammatory complications of specific diseases will, more often than 
is commonly supposed, subside with the primary disease, and — that 
local disorganisations have been in some cases caused by the lower- 
ing means employed. When bleeding from the arm is inadmissible, 
local depletion by cupping or leeches may sometimes be required; 
but even of these we would say that they are not to be used merely 
because there is local evidence of the pneumonia; we must also 
have some increase in the hardness as well as sharpness of the pulse. 

As regards the other means to be employed, amongst which mer- 
cury is the chief, the same caution must be observed ; that is, we 
must bear in mind that the inflammation is essentially liable to 
become disorganising, and, therefore, if the engorgement have led to 
consolidation, we must, when the patient is in a condition to allow 
of auscultation, examine from day to day ; and if we find in the situ- 
ation where the signs of the consolidation were observed, crepitation, 
whether moist or dry, the mercury should be withdrawn, or the 
quantity greatly reduced. The mercury may be combined with 
opium when the latter is not contra-indicated by any tendency to 
head affection, and, where there is not great debility, the tartarised 
antimony may be exhibited at the same time ; though when there is 
bowel irritation, the compound ipecacuanha should be preferred. 

The existence of pneumonia as a complication in fever, ought 
never to deter us from the use of support and stimulants when we 
have evidence of failure of the powers of life, as evinced by the 
same symptoms as in simple fever — accompanied often by the plum- 
juice expectoration — and then the same means already recommended 
must be employed, with the addition sometimes of about fifteen 



TREATMENT OF FEVER. 529 

minims of tincture of squills to the mixture of serpentaria and 
ammonia. 

The treatment of fever with bowel irritation is often most embar- 
rassing ; though the difficulty may perhaps be often avoided, where 
the case comes sufficiently early under our notice, by the rigorous 
exclusion of all the influences, whether in the form of medicine, or 
diet, or external circumstances, which tend to favour this complica- 
tion. On this account, all irritating purgatives should be avoided, 
amongst which must, as regards this disease, be included the saline 
ones, from their effect upon the secretion from the small intestines ; 
and, at the commencement of every fever, where a laxative is indi- 
cated, and there is reason to apprehend a possibility even of this 
complication, the safest that can be used is the hydr. cum cret., fol- 
lowed by the castor-oil, or where we are afraid of the latter offending 
the stomach, the hydr. cum cret. with rhubarb. The same precau- 
tion is necessary in regard to diet — it should from the first be of the 
most unirritating character ; barley-water, milk and water, or even 
rnilk with bread, should constitute the whole, excepting perhaps a 
little tea. Milk, when not disagreeable to the patient, is perhaps the 
best article of diet in fever, until stimulants become necessary, and 
is to be preferred to the beef tea so much used in our hospitals, as 
being less likely to cause or increase diarrhoea. There can be little 
doubt that the tendency to diarrhoea is much increased by impure 
air, especially that loaded with effluvia from organic matter, and 
therefore ventilation and cleanliness are here of special importance. 
In cases of fever with bowel complication, we may allow of a lower 
temperature than in some other forms ; as, for instance, chest-affec- 
tions. 

One great rule is to avoid officious practice': the best medicine 
will generally be found to be the bicarbonate of soda in peppermint 
water, with a little mucilage ; when the bowels are much relaxed, a 
clyster should be administered of about two ounces of starch, with 
from half a drachm to forty minims of laudanum, or an ounce of 
syrup of poppies. When the diarrhoea is excessive, chalk-mixture 
with some additional astringent, as a little tincture of catechu or 
about fifteen grains of extract of log-wood ; though it is better, if 
possible, to prevent the diarrhoea by careful diet than to restrain it 
with astringents. When the powers of life appear to be failing, the 
serpentaria should be used with about fifteen grains of aromatic con- 
fection, and, if necessary, from three to five of sesqui-carbonate of 
ammonia ; wine and brandy are not so early admissible in this as in 
the other complications ; but the former may be administered in 
arrow-root when the pulse becomes feeble and the tongue brown. 
When there is much irritability of stomach, which is not an uncom- 
mon occurrence, besides the application of sinapisms, the occasional 
use of a tea-spoonful of brandy in a wine-glass of soda-water will 
often give great relief. 

34 



I 



530 ERUPTIVE FEVERS. 



XXVIII. 

EKUPTIYE FEVEKS. 

The general laws of idiopathic fever are those of the exanthems. 
Of these, indeed, typhus might be reckoned as one, excepting that 
the exanthems are generally more definite in their symptoms, course, 
and character, under every variety of climate, season, age, and habit 
of body : they are, in fact, the results of specific agents upon the 
system, producing respectively their specific effects, in every instance, 
similar in kind though varying in intensity. They are characterised 
each by its peculiar rash, efflorescence, or eruption, whence the terms 
exanthem (from s^avds^ effloresco), and eruptive fevers. They have 
also each its period of incubation or interval between exposure to 
the poison and invasion of the febrile symptoms ; the period of erup- 
tive fever ; the period of maturation of the eruption ; and in most, 
the secondary fever. The fevers to which this description applies 
are, small-pox, measles, scarlatina, the slight disease varicella or cow- 
pox ; probably also, the plague, and in most respects erysipelas. 

They have also the peculiarity that one attack protects the indi- 
vidual from a second of the same form of epidemic; this law does 
not, however, apply to plague, and is reversed in the case of erysipe- 
las. Individual exceptions also occur in all. 

In the cases of small-pox, measles, scarlatina, and plague, we have 
pretty certain evidence not only that the poison of these diseases is 
communicated by intercourse with those labouring under them ; or 
in other words that they are contagious, but that they never arise 
from any other cause than this specific contagion, exhaled probably 
by the breath of persons affected by them, and also existing in the 
emanations from the surface of the bodies, as is shown by their com- 
municability by inoculation, and by their conveyance in clothes from 
affected persons ; but also that as we now witness them they are 
never produced in any other way. This is not true in the case of 
erysipelas — though it is undoubtedly contagious — and has been 
questioned in regard to scarlatina ; though the occurrence of what 
are termed sporadic cases of the latter, or single cases, in which no 
such communication can be traced, may possibly be accounted for 
by the extreme subtlety of the poison. 

Notwithstanding that the cause of the majority of these diseases is 
contagion, this contagion is controlled by a variety of circumstances, 
affecting not only individuals but the whole population of any town 
or district, as is shown by their spreading at times with great rapid- 
ity, and at times assuming a peculiar virulence. These epidemic 
influences are, no doubt, dependent in a great measure upon ob- 
scure atmosphere or telluric conditions ; but they are also greatly 
aggravated by circumstances arising out of the habits and conditions 
of various populations : such are — the deficiency of ozone or alio- 



SMALL-POX. 531 

tropic oxygen, existing in very densely populated districts,— the 
effluvia arising from defective drainage, and the filth in the dwellings 
of the masses,- — the allowing noxious particles to accumulate, from 
the want of personal cleanliness, and the like. 

The pathology of these eruptive fevers may be summed up as the 
combination of an inflammation of the surface of a specific character, 
with a constitutional fever, of a typhoid type ; but this local inflam- 
mation is not the cause of the fever, since in all cases it follows 
instead of preceding it. The internal inflammations also which 
occur are of a specific character in each respectively, and, therefore, 
to be regarded as the effects of the poison. The danger in these 
fevers depends not so much upon the extent of the external inflam- 
mation, — since it is so important a part of the pathology of some of 
them, that there is danger in arresting the course of it — as upon the 
internal inflammation, and also upon the affection of the general 
system, especially the depressing influence of the morbific agent 
upon the circulation. 

Small-pox is characterised by a tolerably uniform period of incu- 
bation, varying from seven to twelve days, and an eruptive fever of 
about forty-seven hours, a period of from seven to eight days from 
the appearance of the eruption to its completion, and, in severe 
cases, secondary fever of three or four days more. 

The fever of small-pox commences, like most others, with chilli- 
ness and languor, quickly followed by heat, with a dry skin, severe 
headache, and, in the majority of cases, an intense dull aching pain 
in the loins ; sometimes nausea and vomiting, a hard frequent pulse, 
a whitish, furred, and rather dry tongue. These symptoms are not 
all present in every case at the commencement even of a severe 
attack. Much stress is laid by some authors upon the pains in the 
loins, and it is, perhaps, one of the most frequent concomitants of 
the eruptive fever ; and its occurrence, when small-pox is at all pre- 
valent, should, to say the least, excite our suspicions. Sickness is 
another frequent symptom at this period, but not so common as the 
last-mentioned, and to say the least, it is not so constant in this as in 
the inflammatory fever of scarlatina. Some severe cases commence 
with convulsions, and others, which are still worse, with violent 
delirium or coma. 

After the fever has lasted, as before stated, about forty-eight hours, 
though the period admits of variation of from thirty-six to sixty, 
the eruption begins to make its appearance. To this it is most 
important to pay close attention, as up to this period, our diagnosis 
between small-pox and some other exanthems, can be only conjec- 
tural. It first appears at least thirty-six hours from the commence- 
ment of the fever (which is later than in scarlatina, but earlier than 
in measles), first of all in the face, in which respect also it differs 
from scarlatina, and consists, in the first instance, of minute elevated 
papuke, which feel to the finger, like small beads, or millet-seeds. 
These are often surrounded by an erythematous efflorescence, which, 
however, generally disappears after two or three days. After the 
face, the eruption generally appears in the wrists, the trunk, and last 



532 VARIOLA DISCRETA. 

of all, in the lower extremities ; and, in general, the last papulae do 
not show themselves till two days after the first ; that is to say, that 
the eruption begins upon the third day of the fever, but fresh papulae 
do not cease to come out till the fifth. The papulae or pimples gra- 
dually enlarge, and ripen into pustules, showing a depression on 
their tops, on the second day. This appearance is important, as 
affording a distinction from the vesicles of varicella, in which the 
depression is not observed till later ; the suppuration is complete on 
the eighth day of their appearance, when the pustules breaking, 
scabs or crusts begin to form, which fall off in four or five days more, 
the suppuration and incrustation observing the same order as to time 
in different parts of the body, as did the eruption of the pimples. 
This description of the progress of the pustules applies pretty exactly 
to all varieties of the disease. There is, however, a great difference 
in their number, and, in the same proportion, in the severity of the 
disease, the number of the pustules being, as a general rule, an exact 
measure of the extent to which the morbific poison has taken effect ; 
and to which that highly sensitive and important structure, the skin, 
has been involved in the inflammation. In some cases there are but 
a few scattered over the body ; in others, they are crowded together 
in great numbers ; and that may be the case to such a degree, that 
there is not, as it were, room for them to remain separate, but they 
coalesce and run into one-another. This circumstance affords a 
means of distinction into two important varieties. 

As long as the pustules are distinct, and retain individually their 
circular form (though they may be very numerous), the disease is 
called variola discreta, but when they coalesce and unite into irregu- 
lar clusters, or patches of suppuration, it is termed variola confluens. 

In the variola discreta, or distinct small-pox, the eruption follows 
pretty accurately the course which has been indicated, the pustules 
becoming turgid and globular from being filled with pus, but retain- 
ing their central depression, from the pus being deposited not so 
much immediately under the cuticle, as in the areolar tissue, by 
which the summit of the pustule is, as it were, bound down to the 
cutis. As the pustules fill with pus, the parts most affected by them, 
as the face and wrists, become swollen, so much so that the eyes are 
sometimes completely closed ; at the same time, there is often a feel- 
ing of tightness about the fauces, as if from swelling, and the salivary 
secretion is much increased. About the eighth day, a dark crust 
forms on the pustule, the cuticle cracks, and allows the escape of the 
pus, and the pustule gradually shrivels and dries, forming a scab, 
which, in a few days more, falls off, leaving a red skin, which does 
not disappear for several weeks, or a permanent depressed scar which 
remains for life. In this variety of small-pox the fever may be very 
severe at the commencement, but it subsides as soon as the eruption 
is complete, and recurs, after the maturation of the pustules, for three 
or four days in the severer cases, constituting the fever of maturation. 
It is by the appearance of the pustules in the face that we judge of 
the variety to which it belongs, according as they are distinct or 
confluent in that situation. Sometimes, when the pustules are nume- 



CONFLUENT FOEI. 533 

rons, they touch without inosculating or uniting, when the pock is 
said to be cohering, constituting what is in truth a severe form of 
the distinct. 

The confluent form manifests throughout a greater intensity and 
virulence in the morbid poison. The eruptive fever is more violent, 
and the cerebral oppression and disturbance far greater; the fever, 
nevertheless, being of a more decidedly typhus character, the pulse 
being more feeble at the same time that it is more frequent, and the 
tongue more disposed to be brown ; the eruptive fever is shorter, 
the pimples making their appearance earlier about the face, but not 
coming out with the same regularity as in the distinct form, accom- 
panied by a rash not unlike that of scarlatina, so much so as with 
shortened eruptive fever to give rise to some difficulty in the diag- 
nosis. Sometimes, too, the eruption is not unlike that of measles, 
but as regards the diagnosis from the latter disease, the shortness of 
the eruptive fever will prove an assistance. The pimples are also 
less regular in their development than in the distinct form, for, 
though the papulae soon lose all resemblance to that of either scarla- 
tina or measles, by filling with fluid at their summits ; they have 
more the character of vesicles, containing a whitish fluid which after- 
wards degenerates into a brownish colour, and do not plump up into 
true pustules : there is often all this time a livid appearance in the 
surface, between the confluent pustules ; the swelling of the limbs 
and salivation is also greater than in the other variety; sometimes 
there are spots of purpura. There is in this form of small-pox a re- 
mission rather than intermission upon the coming out of the erup- 
tion, and this remission is often but slight, and on the fifth or sixth 
day rigors occur, marking the fever of maturation ; but about the 
eighth day of the rash, and the eleventh of the fever, being the time 
at which the maturation is complete, there sets in the secondary 
fever, the intensity of which is the characteristic of the confluent 
disease. This is the most perilous period of the disorder ; indeed, a 
large proportion of the fatal cases die from the tenth to the four- 
teenth day of the fever, rendering the second the most perilous week. 
Some, indeed, die of this disease in the first week, the nervous sys- 
tem being overwhelmed by the disease, and the patient dying of 
syncope. In the second week, most deaths occur, the patients dying 
from apnoea, through affection of the air-passages ; though subse- 
quent deaths take place, either from asthenia, owing to a want of 
power to recover from the depressive influence of the disease, or 
from the effects of some complication. 

The internal inflammations which accompany this disease are 
mostly those of mucuos membranes, the conjunctivas of the eyes and 
the lining of the fauces being commonly inflamed early in the dis- 
ease, that of the trachea and ^bronchia generally at a later period ; a 
low form of pneumonia may also occur towards the termination. 

After the disease, especially in the severer cases, inilamnuitions 
are apt to occur, which run quickly into suppurations, affecting 
especially the subcutaneous areolar tissue, and the eye, sometimes 
the joints, the pleuras, or the lungs : empyema is a common sequel. 



534: SMALL-POX — PKOGNOSIS. 

The prognosis of small-pox is mainly dependent upon the variety. 
Distinct small-pox is rarely fatal; in the coherent or semi-confluent 
form, the mortality is about one in ten ; in the confluent one in two. 
The favourable circumstances are early and distinct eruptions, pre- 
viously good constitution, previous vaccination, the appearance of 
menstruation at the commencement in females, the swelling of the 
joints at the period of maturation. The unfavourable symptoms are, 
the fever assuming the form of typhus, the pustules becoming flat- 
tened or ichorous, the interstices livid, and sprinkled with petechia?, 
the non-appearance of the swelling at the period of maturation or its 
sudden subsidence, sudden prostration, pallor, great anxiety and op- 
pression at the prascordia, coma, early delirium, syncope, severe affec- 
tion of the larnyx and trachea, subsequent suppurations, and inflam- 
mation of the lungs or pleurae. The danger of small-pox is very 
great in infancy, less in childhood and early youth, and in adults it 
increases with the age. 

In the milder cases but little treatment is required besides a cool 
apartment, good ventilation, light diet, attention to the bowels, mo- 
derate antiphlogistic treatment, as James's powder and salines, and 
watching for internal complications. 

In the severe cases the principle of our treatment must be the 
same, with some modifications, as those of the management of con- 
tinued fever. We must endeavour to control the febrile excitement, 
but we must bear in mind that there is a long and depressing process 
of disease to be gone through, and therefore we must husband the 
powers of the constitution. 

The heat of skin, headache, and throbbing pulse, in the commence- 
ment of the inflammatory fever, might seem to indicate bleeding ; 
but experience has shown us that the amount of the eruption, which 
is the true measure of the violence of the disease, is not affected by 
it, and there is danger of giving a character of typhus to the fever, 
(rentier measures must, therefore, be had recourse to. In the first 
place, then, and before we can be certain of the precise character of 
the commencing fever, we must treat the patient much as in the com- 
mencement of common continued fever. If the bowels have not been 
freely acted upon, we must insure their being well cleared out with 
an efficient but not irritating purgative, as the hydrarg. cum cret., 
followed by castor-oil, or the" combination of rhubarb and calomel, 
and a saline draught should be administered every four or six hours ; 
and when the skin is hot, a pill, as annexed (F. 94),* may be given 
at bed-time, and the same mode of treatment may be continued until 
the eruption is complete ; but when the pulse is compressible, and 
the fever exhibits any tendency to typhus, we must give support 
freely, in the form of beef-tea, broth, and farinaceous substances. 
When there is delay in the appearance of the eruption, or it is of the 
vesicular character, gentle stimulants may be employed, when the 

* (F. 94) R. Pulv. Jacobi veri, gr. iv. 
Hydr. Chlorid. gr. iss. 
Ext. Hyoscy. gr. iv. 
Ft. Pil. ii. To be taken at bed time. 



TREATMENT. 535 

liq. ammon. acet. with, excess of ammonia may be administered ; and 
as in cases of this kind there is only slight remission of the fever 
during the progress of the eruption, and the patient will often be 
very restless at night, we must endeavour to procure sleep by opiates, 
and these are more especially required about the fifth day of the 
eruption, unless they are contra-indicated by tendency to coma. The 
best form of opiate will be about half a grain of muriate of morphia 
in solution, or from twenty to thirty minims of laudanum. "Whilst 
giviug the opiate, we must always be careful to insure at least one 
moderate evacuation for the bowels daily. It is about this period 
that the powers of life may be expected to fail, and if the pulse be- 
come more compressible we must administer wine, and as a more 
efficient stimulant, it will be well to substitute the combination of 
serpenteria and ammonia for that abovementioned. In what has 
just been said we have pointed out the measures required in the 
more dangerous form of the disease, as it is in that only that any 
active interference is required, excepting during the eruptive fever, 
when the treatment will be the same in either case. In the distinct 
small-pox, after the eruption is completed, and in the severer cases 
even before, there is often considerable thirst with difficulty of de- 
glutition, acid drinks are grateful, and as good a form as any is the 
infus. rosse co. When the maturation is completed, there is often 
much irritation from the abraded surfaces ; to allay this, equal parts 
of powdered starch and powdered calamine well rubbed together 
should be sprinkled upon them. 

It must be admitted that, as in continued fever so also in small- 
pox, although judicious treatment may obviate many perils that may 
arise from external or accidental causes, or may keep out of the way 
things absolutely hurtful, still it can do little or nothing towards 
controlling the disease itself; and therefore the only means of arrest- 
ing the mortality which would otherwise ensue from this fearful 
malady is prevention. 

The plan first adopted for this purpose was giving the disease 
to a healthy person by means of inoculation, and it was found that 
thus given it was much milder than when received by ordinary con- 
tagion, or, as it is termed, "in the natural way;" thus inducing an 
immunity, at a diminished risk, from future attacks. This plan, 
which was first introduced into this country by the celebrated Lady 
Mary Wortley Montague, was for many years the only method of 
prevention used. Subsequently, it was discovered by the illustrious 
Jenner that a disease apparently similar, the variola vaccinia, may 
be communicated to man from the cow, and that although an incom- 
parably milder one than variola received from the human subject, it 
has nevertheless nearly, if not equally, the power of protecting the sub- 
ject from any future attack of variola. It may also be transferred 
from one human subject to another by inoculation, and retain the 
same protective power. 

Such are the two measures which have been adopted to guard 
against one of the most fearful scourges that have visited humanity. 
Of the former, it may be said that it was merely the submitting to a 



536 VACCINATION. 

great evil to escape a greater ; that though the inoculated disease was 
much milder than that from ordinary contagion, it was nevertheless 
not very unfrequently severe, and in some few instances fatal; and 
that it is open to the still stronger one that it keeps a pestilence alive 
in a community, since a person suffering from the inoculated small- 
pox can communicate the disease in its severe form to any unpro- 
tected subject. Upon these grounds the practice of inoculation for 
small-pox is forbidden by law in almost every country in Europe ; 
whereas, in most, the vaccine inoculation is more or less compulsory, 
in this country it is now rendered practically so. The small-pox 
from inoculation has therefore become a mere matter of history, 
whilst an acquaintance with the appearance and subsequent effects 
of the disease produced by vaccination has become still more 
necessary. 

When vaccination has been successfully performed, no results 
apparent to the naked eye show themselves till the third day, though 
by the aid of the microscope an efflorescence may be perceived round 
the puncture on the second. On the third day, however, the wound 
is red and elevated, and on the fifth, the cuticle is raised into a white 
vesicle, containing a minute quantity of a thin transparent fluid ; the 
normal form of the vesicle is probably circular; but it may be of 
that shape or oval, according to the mode of making, the incision. 
The vesicle may be said to be perfectly matured on the eighth day ; 
its margin is turgid, and sensibly elevated above the surrounding 
skin;* its colour may be yellowish or pearly; at this time it may 
measure from a quarter to half an inch in diameter. Like the pus- 
tule of small-pox it has the central depression, and like it, it is cel- 
lular ; the lymph being contained in ten or twelve cells. About the 
time of the perfecting of the pustule, the redness which may hitherto 
have extended very little beyond its base, begins to spread and form 
what is termed the areola, which is a red border round the pustule, 
extending more and more till the eleventh day, when it begins to 
fade ; in doing which it becomes livid, then gradually paler, leaving 
behind it a degree of hardness of the surface. About this time a 
brownish crust forms over the vesicle, which becomes harder and 
darker, and if not previously abraded, falls off about the twentieth 
day. Though the disease is so slight, and attended with but little 
constitutional disturbance, there is a certain amount of febrile dis- 
turbance about the eighth and ninth days, analogous to the secondary 
fever of small-pox, marking the affinity of the two diseases. 

For some years after the introduction of vaccination into this 
country there was, as might be expected, a great doubt, and more 
than doubt, in the minds of many, of its efficacy, whereas numbers 
received the evidence of its protective influence in the majority of 
cases, as proof of its effording a complete and permanent security 
in all. The truth, however, lies between the two extremes of 
opinion; vaccination does not afford perfect and permanent security 
through life to all upon whom it may be said to have been success- 

* Gregory's Lectures on Eruptive Fevers. 



MODIFIED SMALL-POX. 537 

fully performed, perhaps not to more than two-thirds ; but there are 
few, if any, of those so operated upon who do not enjoy a great 
immunity from the risks of small-pox, amounting almost to a cer- 
tainty of never being affected by that disease in its dangerous form. 
In many persons the protective influence shows itself not by pre- 
venting an attack of small-pox, but by so modifying it that the dis- 
ease is, as it were, cut short, and subsides before reaching the dan- 
gerous stages; to which it may be added, that the immunity, as 
regards a dangerous attack of small-pox, is, to say the least, as great 
as that conferred by a previous attack of small-pox itself. Certain 
it is, that fatal small-pox in the successfully vaccinated is almost 
unheard of, and it is equally certain that cases are upon record of 
persons dying from a second attack of small-pox. 

As, however, the legislature has practically decided the question 
between inoculation and vaccination, there remains a very important 
one, and that is, the duration, as well as the degree of security con- 
ferred by vaccination. There certainly occurred for several years 
after Jenner's discovery nothing to shake the confidence in the prac- 
tice of vaccination; but, in course of time, cases of small-pox of a 
modified form presented themselves in persons concerning whom 
there was satisfactory evidence of their having been duly vaccinated, 
and these cases became more frequent as there were more and more 
persons living who had been vaccinated ten, twenty, or more years 
previously. The history of these cases certainly favoured the belief 
that the protective power of vaccination diminished in the course of 
time, as numbers who were exposed to contagion in childhood with 
impunity, suffered from modified small-pox in after years. The 
author of the present work was himself exposed purposely to the 
contagion of small-pox, when an epidemic prevailed, and that by 
being on several occasions brought in contact with children suffering 
severely from it, and with perfect impunity (he being then about 
seven years old, and having been vaccinated in infancy), but when 
at the age of twenty-two, suffered from a severe attack of modified 
small-pox; and many cases have occurred under his notice of this 
form of small-pox in persons past the age of puberty, who had been 
vaccinated in infancy, though cases are not wanting of modified 
small-pox in childhood and early youth. The inference from all this 
is, that the protective power of vaccination, in any individual, is 
impaired by time, and that it is probably still further affected by the 
change which takes place in the system at the time of puberty. It 
is, therefore, to say the least, expedient to renew it, and perform 
re-vaccination about the age of sixteen or eighteen. 

The modified small-pox differs from the true in the character of 
the eruption, but still more in the duration and intensity of the fever ;■ 
Dr. Watson mentions three distinct forms : — 

(1.) "The eruption sometimes approaches, in its character and 
course, very nearly to that of the ordinary small-pox ; the pustules 
fill up, have the central depression, and ultimately crust over, and 
the face swells. But this course is performed in a shorter time than 
that of the ordinary disease; and the pustules are usually smaller. 



538 MODIFIED SMALL-POX — CHICKEN-POX. 

This is the severest and least common form of the modified small- 
pox." 

(2.) " Sometimes the papulge show a little fluid on their tops only, 
but never fairly suppurate or break, but the vesicles dry up, and 
hard prominences, with livid bases and horny summits, remain." 

(3.) "There are other cases in which a great part of the eruption 
consists of red pimples, which soon become livid, but contain, from 
first to last, no fluid whatever." 

In most cases all three varieties coexist ; the pustules first appear- 
ing, those, namely, on the face and chest coming to maturity, whilst 
those which last appear, on the legs and feet, for instance, drying up, 
or merely presenting the red pimples. 

The difference, however, in the fever is still greater, and more 
important ; the constitutional disturbance at the commencement, that 
is to say, the eruptive fever, may be at the first as severe as in the 
ordinary small-pox; but just as the pustules are beginning to mature, 
the fever subsides, and the patient becomes convalescent, the disease 
appearing to be mysteriously arrested just at the time when in the 
unprotected it would become most severe and dangerous. To this 
we may add, that most threatening cases sometimes do occur in those 
who have been vaccinated, in which even the fever of maturation sets 
in; but, nevertheless, when we are beginning to fear that the pro- 
tective power of vaccination may have been exhausted, the disease 
suddenly subsides; and this we must never despair of its doing at 
any time. 

The modified small-pox in general requires little or no treatment 
besides antiphlogistic regimen, cool air, and, if necessary, gentle lax- 
atives. Sometimes, indeed, the eruptive fever runs high, and appears 
to threaten the brain, and when this is the case we may use depletory 
measures more boldly than in the unprotected, since the disease has 
not so long a course to run, but these should not be had recourse to 
without urgent necessity. 

The varicella, or chicken-pox, is in itself a disease of little import- 
ance, though it deserves notice from its resemblance to the milder 
forms of small-pox. It affects infants and young children almost 
exclusively. There is scarce any premonitory fever, so that the dis- 
ease is first announced by the eruption, which makes its appearance 
on the scalp, neck, breast, and shoulders, with but very few vesicles 
on the face ; in which respect it differs most from small-pox. The 
eruption consists of perfectly transparent vesicles, of which fresh 
crops continue to appear for two or three days in succession, the old 
ones beginning to shrivel about the third day, after which they 
become pearly and opaline, and leave small dry scabs, which crumble 
away, but sometimes leave shallow cicatrices. These, however, are 
probably the result of suppuration of vesicles which have been 
inflamed by rubbing. 

The important diagnosis of this disease is from small-pox, from 
which it may be distinguished by the absence, or very short dura- 
tion, of the eruptive fever, and by the truly vesicular character of 
the eruption, the vesicles being perfectly simple, consisting, in fact, 



MEASLES — PEOGEESS. 539 

of cuticle detached and raised by the fluid : the effect of which is, 
that the walls of the vesicles, not being kept down by any intervening 
areolar tissue, there is, during the first two days, no central depres- 
sion; it is therefore very important to watch the first appearance of 
new vesicles, as it is only by inspecting them within the first two 
days that we can be perfectly confident that the disease is not small- 
pox, as, after they have began to shrink, and after some have been 
irritated to suppuration by rubbing, it is next to impossible to say 
that the case is not one of either very mild, or modified, small-pox. 

The varicella has the characters of a distinct exanthem: it occcurs 
only once in the same person, spreads by contagion ; it is not, however, 
communicable by inoculation, in which respect it presents a marked 
contrast to small-pox, which even in the modified and mildest form, 
can be reproduced in this way. Another important distinction is, 
that vaccination is no preventive to chicken-pox, and that the pre- 
vious occurrence of chicken-pox does not in any way interfere with 
the regular progress of the vaccine vesicle. It is needless to enter 
further into the question of the identity of small-pox and chicken- 
pox, since it has long been decided in the negative, though there 
may now and then be. great difficulty in the diagnosis between the 
two ; and there is a necessity that when we meet with an equivocal 
eruption, we should enjoin the same precautionary measures as if the 
case were one of undoubted modified small-pox. 

The measles or rubeola, called often by the older nosologists mor- 
billi, is another exanthem, having a distinctive eruption, an eruptive 
and secondary fever, very rarely attacking the same person more 
than once. 

The period of incubation after exposure is about fourteen days ; 
sometimes there is no apparent deviation from health during this 
time, at others, as Dr. Gregory points out, the patient is languid, and 
has ill-developed febrile symptoms for a greater or less portion of the 
time ; so that there .is apparently a greater want of uniformity in the 
premonitory fever of measles than of the other exanthems. In the 
morbilli regulares of Sydenham, the fever sets in in the ordinary 
way, with rigors, pain in the back and limbs, headache, &c, &c; but 
what may be regarded as in a great measure characteristic is, that 
coincident with this, there are catarrhal symptoms, coryza, epiphora, 
sneezing, rawness of the thorax and chest, and pains across the fore- 
head; the pulse is quicker, and the tongue white; the eruption makes 
its appearance upon the fourth day. Dr. Gregory assigns seventy- 
two hours as the standard time ; so that we may lay it down as a rule 
that this eruption is later in making its appearance than either of the 
cognate diseases, small-pox and scarlatina. The eruption begins on 
the face and neck, travels down to the lower extremities, like the 
small-pox, the latest appearing about three clays after the first. The 
papulae begin to fade three or four days after their appearance, so 
that the whole course of the eruption occupies six or seven. The 
eruption consists of small, scarcely-elevated papulae, not presenting 
the millet-seed sensation of small-pox to the fingers, but still percep- 
tibly raised, especially on the face, which is slightly swollen: they 



510 MEASLES. 

coalesce into clusters, which often assume a crescentic, or horse-shoe 
form. The papulae eventually die away in crust, which crumbles off 
in a fine powder. Quite unlike the scabs of small-pox or the des- 
quamation of scarlatina. 

The fever, as already described, is of an inflammatory character, 
more decidedly so than in the other exanthems, and the catarrhal 
inflammation which accompanies it is sometimes severe ; when the 
eruption makes its appearance, there is not uncommonly diarrhoea, 
showing the disposition of the disease to attack the mucous mem- 
branes : at this time, too, the fever and catarrhal inflammation both 
become more severe, and continue until the eruption has covered the 
whole body, in which respect this disease presents a contrast to small- 
pox. Another remarkable point of difference is, that in measles the 
danger is mostly in an inverse proportion to the eruption ; its chief 
source being apparently the inflammation of the mucous membrane, 
to which the eruption appears to act as a revulsive. In the gene- 
rality of cases the fever and inflammation both begin to decline when 
the rasb begins to fade upon the face — that is to say, on the fourth 
day of the eruption; about this time, also, there is sometimes diar- 
rhoea, which seems to afford considerable relief. 

In the severer cases, however, the symptoms, both general and 
local, become increased in intensity at the subsidence of the eruption ; 
the bronchitis extends into the smaller tubes ; and to it is often added 
pneumonia, which may prove fatal in either by apnoea or exhaustion : 
in some cases, too, the fever assumes a typhoid form : sometimes there 
is exhausting dysenteric diarrhoea. It is not very uncommon for the 
eruption to recede suddenly (in some instances, as we have reason to 
believe, from imprudent exposure, but in others spontaneously), when 
some of the unfavourable symptoms above described will manifest 
themselves. 

The diagnosis of the disease is not difficult, depending upon the 
character and duration of the eruptive fever, and the appearance and 
progress of the eruption. The eruption may be said to be the true 
characteristic, and without it we can never pronounce a case to be 
measles, though sometimes there is the true rubeolous rash, preceded 
by slight fever, but without any catarrhal symptoms appearing, when 
measles is prevailing epidemically — a disease which has been de- 
scribed under the term rubeola sine catarrho. This affection, however, 
bestows no immunity against the true disease, by which it is often 
quickly followed. 

The prognosis and treatment of measles are, as it were, corollaries 
to its history and progress. The most favourable signs are an abun- 
dant rash, persistent for the full period, fever of sthenic but not 
violent character, absence of pneumonia or capillary bronchitis, and 
the decline of the symptoms with the fading of the rash, with free 
spontaneous action of the bowels at this time. The untoward events 
or signs are scanty eruption, and still more its sudden arrest or retro- 
cession ; fever manifesting a tendency to typhus, capillary bronchitis, 
pneumonia, aggravation of the symptoms at the subsidence of the 
eruption, constituting a species of secondary fever. Independently, 



SCARLATINA. 541 

however, of its immediate fatal results, measles often induces serious 
secondary consequences, or excites latent tendencies to constitutional 
diseases. The most frequent instance of this is the calling into 
activity any tendency to tuberculosis, when in children of this dia- 
thesis there ensue strumous enlargement of the glands, scrofulous 
affections of the eyes, joints, or other parts, tuberculous disease of the 
lungs or of the encephalon. In the milder forms of measles but little 
treatment is required : the patient should be kept moderately warm 
in bed, and a saline mixture administered of either acetate of ammo- 
nia or citrate of potass, with a few minims of antimonial wine, and 
tincture of hyoscyamus or conium; if the eruption should recede, 
the patient must be placed in a warm mustard bath. The great 
danger arises from the bronchitis or pneumonia. We must carefully 
watch for the symptoms of these complications, and treat them 
according to their extent and intensity much as when they occur 
idiopathically. When these are detected early, moderate depletion 
may be had recourse to, and will be well borne, and moderate doses 
of calomel with Dover's powder, or antimony with opium, may be 
employed. Blisters may also be used when the more active symp- 
toms have been subdued, unless, as is often the case in scrofulous 
children, there is a liability to troublesome sores, when they had 
better be avoided; in such subjects, if blisters have become necessary, 
it is best to apply one, only for one or two hours, according to the 
age, and then remove it, and if at the end of an hour there is no vesi- 
cation, to repeat it ; or after the blister has been applied for two or 
three hours, to remove it altogether, and apply a linseed poultice in 
its place. If typhoid symptoms should show themselves, the case 
must be treated as one of low fever, with the cautious use of ammo- 
nia and other stimulants. As the diarrhoea which comes on upon 
the subsidence of the eruption is often sanatory, we must endeavour 
to induce it, should it not occur spontaneously, by gentle purgatives. 

Great care is required, in the after-management of measles, to 
prevent cold, by the use of warm clothing, and avoiding too early 
exposure out of doors. 

Another eruptive fever, of frequent occurrence, and in too many 
cases of a fatal tendency, is scarlatina, or scarlet fever. The former 
term is a corrupt word, which custom has sanctioned amongst nosolo- 
gists and professional men, and which it would be well if we could 
replace by the English noun, scarlet fever; but there is a difficulty in 
all reforms of this kind, and in this particular instance we are often 
induced to use the word "scarlatina" in accordance with the preju- 
dices of the vulgar, who, from its termination resembling that of a 
diminutive, are much less alarmed by the word than- if Ave were to 
speak of scarlet fever. Hence, therefore, we adopt the mongrel word 
as a sort of euphemism for the English. 

By whatever name, however, it may be called, it is a most destruc- 
tive disease, and one the mortality from which appears to have boon 
of late years increasing. Like the other exanthems, it has its period 
of incubation, its period of eruption, and its secondary fever. Be- 
sides this, as the scarlatinal poison, like others of a kindred nature, 



542 SCAELATINA SIMPLEX. 

has a tendency to concentrate itself upon particular parts, inducing 
complications, which in many cases are to all appearance the natural 
consequence of the disease, and yet are not integrant portions of it, 
since it may run its course without their happening. Scarlatina has 
most of the characteristics of a true exanthem ; it is highly contagious, 
though, no doubt, the susceptibility of a whole population may be 
greatly influenced by atmospheric and other causes, and therefore it 
sometimes spreads with great rapidity, or, in other words, prevails 
epidemically: it rarely attacks a person a second time. It is particu- 
larly fatal to young persons. The susceptibility to the poison appears 
to be greatest from infancy to puberty, after which it appears gradu- 
ally to diminish as the subject grows older, ceasing entirely about 
forty ; though some few instances do occur after that age. Women, 
however, in the puerperal state are very susceptible to it; at least, if 
they are not attacked oftener than others of the same age, the dis- 
ease in them is more likely to be fatal when it does occur. 

Scarlatina then has a period of incubation of from ten to fourteen 
days, and during that time the patient commonly appears in his 
usual health. It makes its first invasion with ordinary signs of 
pyrexia, severe headache, and very commonly sickness, and on the 
second day an efflorescence is observed on the neck and breast. 
This extends upwards, generally towards the face, and downwards 
over the trunk and lower extremities : in the former situations the 
rash makes its appearance in large bright, red blotches, of indeter- 
minate form ; often nearly the whole surface is of this colour through- 
out: on the extremities it puts on more of a spotted appearance, 
which it is possible to mistake for measles, though there are no true 
papulae, the cuticle not being elevated as in the last-mentioned dis- 
ease. During this period the pulse is sharp and frequent, the skin 
hot, the tongue coated, generally red at the edges, with very elon- 
gated papillae. In uncomplicated • scarlatina, the rash keeps well out 
for from three to four days ; it then begins to decline, and fades 
away altogether about the seventh ; soon after this, desquamation of 
the cuticle commences in the form of scurf, from the face, neck, and 
trunk ; but in large scales or rather sheets from the extremities ; 
sometimes the whole cuticle of the hand has come away like a glove. 
The fever has now, to all appearance, run its course, but it is evi- 
dent that even now the poison has not been entirely eliminated ; or, 
as others would rather have it, the series of morbid phenomena is 
not complete ; since even after this mild form of the disease, we not 
uncommonly find subsequent lesions of other organs, apparently the 
effect of the morbid poison locating itself in them. Such is the 
simple, uncomplicated scarlet fever, the scarlatina simplex of noso- 
loarists. 

o 

This exanthem, however, more commonly presents itself in a 
severer form, in which the morbid poison attacks the fauces and 
tonsil glands. In this, the scarlatina anginosa, the fever sets in much 
in the same manner as in the preceding, but is accompanied or 
shortly followed by a sense of stiffness about the muscles of the neck 
and throat ; the characteristic tongue, with red edges and elongated 



ANGIXOSA — MALIGNA. 543 

papilae, shows itself almost from tlie commencement, and upon look- 
ing at the fauces, we perceive the tonsils and uvula to be swollen. 
This swelling, and with it the general fever, continues to increase, 
and swallowing and deglutition become painful, and often the respira- 
tion is difficult, and the patient lies with the head rather thrown 
back. At the earlier period, the pulse is quick and sharp, but in 
most cases, readily compressible. The tonsils continue to enlarge, 
and there is often much stiffness of the jaws ; so that it becomes 
very difficult to inspect the fauces, which are commonly covered 
with apthous crusts. These crusts are often mistaken for ulceration, 
which, though not very common, does sometimes occur. The en- 
larged tonsils may be felt externally and the glands about the throat 
swell likewise. The pressure thus produced upon the large vessels 
no doubt promotes congestion in the brain ; but, independently of 
this, there is sometimes early delirium, and as the disease advances, 
there may be tendency to coma. The inflammation about the throat 
extends often to the mucous membrane of the nostrils, and a sanious 
ichor flows from them ; the lining membrane of the eustachian tube 
becomes likewise affected, and the inflammation spreads along it to 
the internal and external ear, and there is often an irritating dis- 
charge from the latter ; the eye may also become affected in like 
manner, and sometimes the areolar tissue of the orbit. The mucous 
membrane of the larynx may also become the subject of inflamma- 
tion, producing sometimes death from suffocation, by the obstruction 
caused by the consequent swelling. The serous membranes, too, of 
the head and chest may likewise become implicated, and of these 
the tissues most likely to be affected are the arachnoid and the peri- 
cardium. Scarlatinal pericarditis is perhaps a more common affec- 
tion than most practitioners are aware of. 

It is about the fourth day of the fever, when the rash begins to 
decline, that these complications are most likely to ensue, and there- 
fore this may be regarded as a period of great danger, though in 
those cases in which there are no complications beyond that of the 
throat, there is great danger about the eighth day, when the febrile 
symptoms assume more the character of typhus, and the patient 
sometimes sinks under the depression produced by fever, aggravated, 
it may be, by the protracted suffering : but he will generally do well, 
as regards the immediate danger, if he survive the eighth or ninth 
day. 

The last form of this disease' which we have to notice, is the scar- 
latina maligna, than which a more fatal one is not to be found in the 
whole range of nosology, or one which more speedily and entirely 
crushes the powers of life. In the scarlatina simplex, the amount or 
intensity of the poison appears to be small, and it is not even concen- 
trated in any single part; in the scarlatina anginosa there is danger 
owing to the poison locating itself and setting up a specific inflam- 
mation in an important and susceptible part; but in this the inten- 
sity or virulence of the poison is such that all the forces of the sys- 
tem — the nervous power, and the action of the heart, as well as the 
vital affinities of the extreme circulation — appear to be destroyed, or 



544 SCARLATINA MALIGNA. 

at least suspended, although in this form, as in the last, the poison 
exhibits a tendency to localise itself in the fauces. 

The initiatory fever of this malignant scarlatina differs from that 
of the other forms only in its greater intensity, and in its greater 
proneness to assume the character of typhus. There is great oppres- 
sion in the countenance, the eyes are suffused, the oppression about 
the prsecordia and the general prostration are greater, and the pains 
in the back and stiffness in the muscles of the neck are more severe ; 
the pulse is small and feeble, and the fauces, when inspected, present 
a dusky-livid appearance. The eruption is generally late in making 
its appearance, and when it does, it is livid and often interspersed 
with spots of purpura. The poison, as before observed, early attacks 
the throat, which, upon inspection, is seen to be dusky, swollen, and 
livid. There is an offensive foetor in the breath, which, when once 
observed, is again readily recognised; ashy sloughs form upon the 
tonsils, which ulcerate and sometimes become gangrenous. The 
voice is hoarse and the respiration performed with a difficulty 
almost like that of croup. The throat becomes clogged with a glairy 
phlegm, which the patient in vain endeavours to expel, and the 
sanious ichor before mentioned streams from the nostrils, causing 
excoriation of the upper lip, and ulceration of the angles of the 
mouth. 

Delirium, sometimes of a low muttering kind, sets in early; in 
other cases there is a tendency to coma, and in others violent maniacal 
excitement seizes the patient suddenly. As has been before pointed 
out, the poison seems to destroy the natural vital affinities of the cir- 
culating fluid; and, as a consequence, general capillary congestion, 
shows itself in the air-passages by wheezing and urgent dyspnoea, 
and, in the alimentary canal, by irritable bowels and bloody stools. 
Sometimes the effects of this congestion are manifested by early 
collapse, the surface becoming cold, dusky, and shrunken, especially 
in the extremities, and the pulse at the wrist nearly imperceptible. 
Should the patient linger to the eighth or ninth day, there will gene- 
rally be then an aggravation of the fever, and the patient will die, 
either from sinking, or from apnoea owing to congestion of the lungs, 
or from coma produced either simply by the effects of the poison 
upon the brain, or by the congestion produced by the pressure of the 
swollen glands upon the large veins in the neck, which also tends 
greatly to aggravate the dyspnoea. 

It has been already stated that in this, the malignant form of scar- 
latina, the rash is generally late in making its appearance, but in 
some cases it never appears at 'all. Thus cases now and then appear 
of putrid sloughing of the throat, without any rash whatever, tending 
rapidly to death by sinking, and of which it is at first very difficult 
to discover the origin. Subsequent cases of scarlatina, obviously 
traceable to communication with the patients so affected, leave no 
doubt as to the real nature of the disease. But this is not all; some- 
times young persons who have been in undoubted intercourse with 
others labouring under this disease, have died almost suddenly; in 
some instances, no cause for death could be found, upon careful 



MODES ON DEATH. 545 

examination. Now, when we consider the rarity of sudden death in 
childhood (we do not mean infancy) and youth, and when we take 
into account also the acknowledged virulence of the poison of scar- 
latina, it is not too much to believe that it may have produced death 
by its direct influence upon the nervous or circulatory system. In 
other cases, again, death has taken place very speedily in young per- 
sons exposed to scarlatinous poison, and, upon examination, the cause 
has been found to be internal inflammation, often of a puriform char- 
acter. In one instance, a child, previously healthy, became collapsed, 
without much pain in the abdomen, but with apparent distress about 
the epigastrium, had some sickness, and died in a few hours. In this 
case, there was found peritonitis somewhat of a puriform character, 
involving the peritoneal surface of the duodenum and of a portion of 
the stomach and neighbouring viscera. 

Thoiigh scarlatina, in its severe forms, is so frequently fatal during 
the fever, the danger does not stop there, and therefore the sequels 
of the disease deserve attention. The most familiar of the sequels of 
scarlatina is the process of desquamation. This is itself a reparative 
process, being the mere falling off of the dead cuticle, to make room 
for the new; but till this process is completed, the susceptibility of 
the constitution is great, and the functions of so extensive and import- 
ant an organ as the skin, being liable to disturbance from changes of 
temperature, there is, as might be anticipated, a corresponding dan- 
ger of disease of the complementory organs — the kidneys, — hence, 
for want of caution at this time, we may have the scarlatinal dropsy, 
of which, for convenience' sake, we have spoken in connection with 
diseases of the kidneys. 

Dr. Gregory remarks, with truth, that when there has been serious 
anginose affection, the cellular membrane of the neck will often take 
on inflammation; erysipelatous redness of the neck, with great hard- 
ness and swelling are perceived; the cellular membrane sloughs; 
this sloughing, if extensive, brings life into hazard. This observa- 
tion is important, both for a caution in practice to be presently 
noticed, but also as an instance of the close affinity between scarlatina 
and erysipelas. This tendency, to excite inflammation of the areolar 
tissue, does not, however, confine itself to that particular part, as it 
may also show itself in the same tissue elsewhere; as, for instance, 
in the orbit. The ear, as we have remarked, often becomes inflamed 
during the fever, and the inflammation may assume a more chronic 
character, and continue after the subsidence of the former, becoming 
sometimes of a puriform nature, with a highly offensive odour, and 
leading to the destruction of the bones of the ear. The ulceration 
sometimes extends also to the petrous portion of the temporal bone, 
producing in some instances inflammation of the membranes, and in 
others abscess in the substance of the brain. 

It is remarked by Dr. Gregory, that scarlatina differs from measles, 
in that the former is accompanied and followed by phrenitis and 
dropsy, while measles is by pneumonia. The same proposition might, 
perhaps, be enunciated in more general terms, by saying that scar- 
latina has a greater tendency to attack the serous membranes ; pos- 

35 



546 S C A R L A T I N A. 

siblj this may be dependent on the connection between scarlatina and 
Bright's kidney, in which there is so remarkable a liability to serous 
inflammation; it is evinced by another sequel of scarlatina not very 
generally noticed, arthritic inflammation resembling rheumatism. 
In whichever way we account for it, we certainly meet with inflam- 
mation of the serous membranes, sometimes without any albumen in 
the urine, sometimes with arthritic inflammation, and sometimes 
without it; the proneness of the different serous membranes fol- 
lowing much the same order as in rheumatism; the pericardium 
becoming most frequently involved next to the pleurae and mem- 
branes of the brain, and, lastly, the peritoneum. 

Of the prognosis of scarlatina we need add little after what has 
been already stated, the diagnosis must also in the same way be 
tolerably apparent. We may, however, remark, that not only in the 
subsequent inflammation, but also in the appearance of the eruption, 
scarlatina will sometimes closely simulate erysipelas. The close 
affinity of these two diseases has not perhaps generally received the 
attention which it merits. 

Like all virulent and dangerous diseases, scarlatina has had its 
share of "certain cures," but when these are tested by the truly 
malignant forms, they prove as certain failures. 

The scarlatina simplex is, as we have stated, a very mild disease, 
going on spontaneously to a favourable termination, and needing 
little treatment; in such cases, then, the "nimia medici diligentia" of 
Sydenham should be sedulously avoided. Even here, however, care 
should be taken to avoid over-exertion and exposure to cold, till the 
desquamation has been completed ; since such cases do not appear to 
be more exempt from the invasion of scarlatinal dropsy than are the 
more severe. Dr. Gregory appositely remarks, that we may as sum- 
marily dispose of the treatment of the typhoid form of the disease, or 
scarlatina maligna: this in spite of all vaunted specifics, should be 
treated according to the dictates of common sense; that is to say, by 
support and stimulants, from the first evidence of the true character 
of the attack. Grood beef tea should be early administered as freely 
as the patient can take it ; and as the powers of life begin to fail, as 
shown by the dry brown tongue, black sordes about the mouth, 
dusky extremities, and feeble pulse, wine should be given, not 
according to measure of ounces, but to its effects upon the circula- 
tion. Of medicines, strictly so called, ammonia is the best of stimu- 
lants. Some practitioners have imagined that it has an almost specific 
influence upon the disease; but whether that be so or not, its use in 
the malignant cases should never be omitted, provided the patient 
can swallow it. The best form for its exhibition is the mixture of 
serpentaria and ammonia (p. 549). When the pulse becomes, as it 
sometimes does, nearly imperceptible at the wrist, ether may be 
added. It may be well, too, at the commencement of such cases, 
when the skin is hot over the whole surface, to add the liquor ammon, 
acet., in doses of one or two drachms, according to the age. As the 
ammonia is sometimes irritating to the fauces, so much so that it 






TREATMENT. 547 

cannot be taken, we must then have recourse to other stimulants ; 
the tincture of bark may then be used, and with it ether, in infusion 
or decoction of bark, and in such cases small doses of the chlorate of 
potass may be added. Some practitioners place great reliance upon 
this salt, and certainly it is not undeserving of trial when the ammo- 
nia is found inadmissible ; when that is not the case it should not 
supersede its use, though a solution of one drachm of the chlorate in 
a pint of water may be used for a drink, which will be neither unplea- 
sant to the patient, nor inconsistent with the exhibition of the am- 
monia. 

The great difficulty, however, is in the management of the inter- 
mediate cases, because here the result is more influenced by the 
treatment employed. In the invasion of the disease, the skin being 
hot, and the arterial excitement great, the obvious indication seems 
to be to lower them by decisive measures; but here, as in all specific 
fevers, we must remember that the poison is of a depressing character, 
and that the disease has a determinate course to run ; for the latter 
reason, and still more from the test of experience, we may say that 
the abstraction of blood is, as a general rule, inexpedient; there 
may be cases in robust subjects, with a full, strong pulse, where it 
may be borne ; such, however, are exceptional. Another means 
which has been recommended to fulfil the above indication, is the 
administration of an emetic at the onset, and this should be done 
then, if at all ; but the success of the practice is doubtful. "Vomiting 
often comes on spontaneously, and this sickness is certainly a general 
symptom in some very mild epidemics ; still Dr. Gregory regards it 
as in itself unfavourable. — We should have some hesitation in adopt- 
ing the practice. There is, however, another safer means of lowering 
the vascular excitement, and that is by a moderate but efficient pur- 
gative. We do not by this mean that purgatives are to be employed 
blindly, but that when we are sure that there is no tendency to diar- 
rhoea, and have reason to believe that the bowels have not been 
freely acted upon within the preceding twenty -four hours, a moderate 
dose of rhubarb and calomel, or of scammony and calomel, will be a 
safe remedy. 

The practice of cold affusion, as introduced by the late Dr. Currie, 
of Liverpool, is another of the means proposed for keeping down the 
fever, and cooling the surface ; but though, in those cases to which it 
is applicable, it is a grateful and efficient remedy, the number of such 
is very limited, and, unfortunately, does not include the most dan- 
gerous; "it is adapted," says Dr. Gregory, "for young persons with 
high anginose inflammation and a burning hot skin," but unfortu- 
nately, it is not applicable, on the one side, to cases of plethora, or 
on the other, to those of debility. The tepid sponging recommended 
as a substitute, is a useful auxiliary at a later period. 

The practice most applicable to those cases which require decided 
remedies, and can be benefited by them, will be, as Dr. Watson well 
observes, that which is proper for many cases of continued fever ; it 
is one to which the author has been driven, or rather which he has 



548 SEQUELS OF SCARLATINA. 

been compelled to fall back upon, after no inconsiderable experience 
of this distressing malady, and glad is he to find himself in accord- 
ance with that judicious and accomplished physician. 

The first thing to be done is to insure the free evacuation of the 
bowels, either in the manner above recommended, or by a moderate 
cathartic draught ; put the patient in the best ventilated apartment 
at command, and remove all bed-hangings ; without good ventilation 
you can do nothing ; keep the surface as cool as possible, by not 
allowing the patient to be overwhelmed with bedclothes. In the 
sinking cases, it is true, the extremities are apt to become cold, and 
this must be guarded against ; but, as a general rule, let the cover- 
ings be light. Keep the head cool, and remove all superfluous hair; 
if there be delirium threatening, or head-affection, it must be shaved. 
The patient may then be put upon the use of the liquor amnion. 
acet. ; and if the skin be very hot, it may be sponged with tepid 
vinegar and water. The acid gargles, as that of infusion of roses 
with sulphuric acid, are agreeable in mild cases, and cleanse the 
throat; but when there is any ulceration or excoriation, they cause 
pain; the gargle of mel rosse and bark will then be preferable; lime 
water with honey is also a useful cleansing gargle, or a mixture of 
chlorate of soda and water in the proportion of a drachm to a pint. But 
a most valuable means of checking the inflammation, is the applica- 
tion of the nitrate of silver, either in substance or in a strong solu- 
tion, to the uvula and tonsils, and around the fauces as far as it can 
be effected, and this may be repeated after twelve hours if possible. 

We must now watch carefully for the invasion of carebral symp- 
toms in the way of active delirium, and when these occur in mo- 
derately strong subjects with a firm pulse, a little blood may be 
abstracted by leeches ; some writers recommend their being applied 
to the throat rather than to the temples, but against this practice in 
general, objections have already been stated: the best situation is, 
however, over the mastoid processes, where they are not likely to 
produce the same inconvenience, and where, should the bleeding be 
too profuse, which it is apt to be in scarlatina, especially with chil- 
dren, pressure can be conveniently applied. Our attention must 
still be directed to the throat, and as the disease advances, if the 
swelling continues, hot well-made linseed poultices should be applied 
externally. The bowels should throughout be carefully watched, as 
much with the view of preventing costiveness as of checking diar- 
rhoea ; for the former purpose a moderate dose of castor-oil is the 
safest ; for the latter a starch enema, with syrup of poppies, or, the 
chalk mixture with aromatic confection, may be given. The powers 
of life should now be carefully sustained : milk, or milk and water, 
and beef tea should be given as nourishment ; and when the pulse 
begins to grow feeble, or even decidedly compressible, gentle stimu- 
lants must be employed. Of these the best is the sesquicarbonate of 
ammonia, which may be added in excess to the acetate. If the pros- 
tration still increase, the tongue become brown, and sordes begin to 
accumulate about the teeth, the serpent-aria, with bark and ammonia, 



ERYSIPELAS. 549 

may be used (F. 95).* About the same time, too, we may commence 
the cautious administration of wine, carefully watching its effects, 
and regulating its quantity accordingly. 

Of the management of scarlatinal dropsy we have spoken else- 
where ; we need therefore merely urge the necessity, in all cases, of 
using every precaution to prevent any chill to the surface, until the 
desquamation is entirely completed, which will not be till the end of 
three weeks, or sometimes more; and during this period the urine 
should be from time to time tested for albumen. It is in the fourth 
week that we most frequently meet with the dropsy, which is in many 
cases preceded by headache, dyspnoea, or pains in the loins; in some 
very severe cases it is ushered in by convulsions ; in others, however, 
it creeps on quite insidiously. 

The rheumatic sequels of scarlatina do not appear to have received 
the attention from authors which they deserve. Most practitioners 
must be familiar with the fact of arthritic swellings of a very trouble- 
some character occurring at the close of scarlatina, though many 
have doubted the identity of these with rheumatism ; but not only 
have these arthritic swellings a close resemblance to that disease, but 
there is the same tendency to metastasis of the inflammation to the 
heart and pleurae. 

The treatment of those affections requires considerable caution, 
since after so depressing a disease as scarlatina the patient has rarely 
strength to endure the measures ordinarily adopted for the cure of 
acute rheumatism. When it is confined to the extemities, the treat- 
ment of the arthritic affection with the acetate and nitrate of potass, 
in the manner already pointed out, will best fulfil the indications ; 
and when cardiac inflammation supervenes, the same practice may 
be continued, with the addition of moderate doses of calomel and 
opium ; as, for instance, a grain of calomel with half a grain of opium 
may be administered every four hours ; and if there be no great heat 
of skin, a blister may be applied to the region of the heart. 

Another disease of which it is most expedient to treat in connec- 
tion with this exanthem, is erysipelas, a disease about which there 
exists much difference of opinion upon almost every point, not only 
as regards the meaning and derivation of the term, but also as to noso- 
logy, its pathology, its origin and treatment. As regards its place 
in a system of nosology, that is now a matter of but little import- 
ance ; but we deem it expedient to treat of it in connection with the 
exanthemata, though reasons might be urged for placing it amongst 
the phlegmasia^ ; the truth is, that it holds a middle place between 
the two, partaking, as we shall see, of the characters of both. 

Erysipelas has, according to some, a period of incubation of about 

* For instance — 

(F. 95) R. Ammon. Sesquicarb. gr. xviij. 
Tinct. Cinchonse co. £ iv. 
Tinct. Serpentarise, 3 iij. 
Syrupi Aurantii, 3 iij. 
Infus. Serpentarise, q. s. to make a 5 iv. mixture of the one-sixth portion is to be 
given every fourth hour, to a child of ten years. 



550 ERYSIPELAS. 

a week, though, this does not seem to hold true of all cases. It 
sometimes begins without any previous signs of fever ; this applies 
only to the mildest cases ; in the more decided there is an eruptive 
fever, commencing with rigors, languor, pains in the limbs, fol- 
lowed by increased heat of skin, frequently sickness and vomiting, 
headache, thirst, restlessness, &c. ; a white tongue, sharp pulse ; with 
the fever there is often an inflammatory state of the fauces, of 
greater or less intensity. After a period, varying from twenty -four 
to sixty hours, but generally about thirty, a redness appears most 
commonly upon the face, sometimes, though not so often, upon the 
legs, and still more rarely upon the trunk. The redness is soon fol- 
lowed by heat and tension of the part, and this redness, pain, heat, 
and swelling evince a disposition to spread to the surrounding parts 
(whence the name of the disease). When the eruption attacks the 
face, it is almost always the side of the nose, close to the inner angle 
of the eye, which is first affected. The swelling soon involves the 
whole of the eyelids, which assume a characteristic cedematous ap- 
pearance, and the eye is often closed ; it then generally spreads over 
the whole face, and on to the scalp, sometimes extending down the 
throat or the back of the neck ; in some instances it descends even to 
the extremities, and does not subside until it has invaded every part 
of the surface. 

The eruption of erysipelas appears to consist in an inflammation 
of the cutis, apparently differing but little from that set up by can- 
tharides or scalding water; the inflammation producing, as in the 
latter instances, an effusion of straw-coloured fluid (though, in some 
cases of a low type, this fluid may be a sanious ichor), which sepa- 
rates the cuticle from the castis vera, forming blebs or blisters of 
different sizes. These generally break and discharge their contents, 
and the raised cuticle dies off in scales, leaving a red or livid surface, 
according to the less or greater typhoid tendency in the patient ; the 
whole process of desquamation being generally completed in a fort- 
night. The inflammation, however, in the severer cases is not con- 
fined to the skin, but extends to the subjacent areolar tissue, consti- 
tuting one of the severest forms of what used to be called " cellular 
membranous inflammation." In this inflammation there is, as might 
be anticipated, little or no plastic power, the effusion being at best 
but of the character of molecular lymph, and in a large number of 
cases puriform ; and there being little or no power to circumscribe 
the effused pus with plastic lymph, extensive and destructive gan- 
grene supervenes. 

Whilst all this mischief is going on upon the surface and in the 
areolar tissue, the constitution sympathises, as might be anticipated. 
In the milder cases, the fever gradually subsides without its assum- 
ing a low type, or any dangerous complications arising, and the 
patient is convalescent in a few days. In the more severe, the 
tongue becomes brown, the pulse compressible, the eruption livid, 
and the patient is reduced to the condition, of the lowest typhus. 
The swelling of the face in such cases is often so great as entirely to 
obliterate the natural features, and give the patient a most frightful 



PROGRESS — CAUSES. 551 

appearance. In this form of the disease the patient may die of 
exhaustion within a week, often about the fourth or fifth day. 

Besides the direct effect of this fever upon the system, there is 
another cause of depression in the puriform infection, from the dif- 
fuse suppurative inflammation, not to mention the probable depres- 
sing effect upon the nervous system of extensive inflammation of a 
part to which is distributed so abundant a supply of sentient extrem- 
ities of nerves, as is the case with the skin : but, besides these, there 
are apt to arise dangerous complications, the organ most likely to be 
so affected being the brain. Delirium, sometimes of a fierce charac- 
ter, at others having more that of delirium tremens, may suddenly 
set in, and the patient dies comatose about the eighth or ninth day. 
Some pathologists regard this as the effect of metastasis to the brain, 
and though Dr. Gregory regarded this proposition as untenable, 
there are facts in its favour, such, for instance, as the delirium super- 
vening upon the inflammation about the head being checked by cold 
applications, and its subsiding upon the use of external irritation. 
In these cases the brain presents no morbid appearance after death 
beyond mere engorgement of the vessels. The stomach is sometimes 
attacked, the symptoms being uncontrollable sickness, with a ten- 
dency to rapid exhaustion. There is in children a great liability to 
muco-enteritis when attacked by this disease. Erysipelas also attacks 
the serous membranes much in the same way that scarlatina does ; 
and another point in which it resembles that disease is its tendency 
to attack the throat. This it does in a still more dangerous manner, 
the inflammation extending often to the epiglottis and larynx, and 
causing death from apnoea. 

The tendency of erysipelas to excite puerperal peritonitis has been 
already noticed, and it is remarkable that handling the affected peri- 
toneum in dissecting a subject that has died of the latter disease, is 
very likely, if there be any excoriation, to set up erysipelas of a 
formidable character. 

The cause of erysipelas is to this day rather an agitated question, 
though perhaps few will now be found hardy enough to deny that it 
may be propagated by contagion ; or, on the other hand, that com- 
munication with an infected person is its alone cause. It is also 
miasmatic ; that is to say, either excited, or its diffusion promoted, 
by some atmospheric or other epidemic influence, as in several sea- 
sons it spreads with unusual rapidity ; though, whether this may 
arise from any specific poison pervading the atmosphere, or merely 
from the season being such as to induce a weakness of body in which 
there is less power of resisting the poison when applied to it, may 
admit of dispute. The spread of erysipelas is greatly facilitated by 
neglect of cleanliness, defective ventilation, and overcrowding of sick 
persons in the same apartment, as in the wards of an hospital ; want 
of attention to these particulars favouring the development of what 
has been termed hospital miasma, which is characterised by the 
extension of erysipelas and its kindred disease hospital gangrene. 
Erysipelas often attacks wounds and sores, and is therefore peculi- 
arly to be dreaded after accidents and operations. With regard to a 



552 ERYSIPELAS. 

poison so subtle and so easily conveyed as is that of erysipelas, it is 
difficult to give a positive answer to the following queries : — Whe- 
ther it ever appears in its worst form in the wards of hospitals, &c, 
without being imported, and whether it spreads in such situations 
independently of any prevailing atmospheric or other epidemic influ- 
ence ? In regard to the first of these queries, it is highly probable 
that it may so arise, and that it would more frequently do so but for 
the great precautions that are now used. On the other hand, how- 
ever, the majority of cases that do occur at Guy's, particularly, may 
be traced to importation from without, and its extension in the medi- 
cal wards especially has been pretty effectually checked by the 
exclusion of such cases, and the speedy removal of any that may 
occur. 

We have already spoken of breach of surface (and of this class of 
causes there is none which is so likely to excite erysipelas as leech- 
bites) as inducing susceptibility, if not sometimes acting as the direct 
and immediate cause of erysipelas itself — exposure to cold is another. 
There is also a certain constitutional, and, apparently, congenital sus- 
ceptibility inherited by some persons, so that the slightest exposure 
to cold, the merest scratch, or the application of a single leech will 
induce erysipelas. This is often so slight an affection that it may 
well be doubted whether it is essentially the same disease, more par- 
ticularly as it rarely or never propagates itself by contagion; this 
opinion, however, does not seem to be warranted upon other grounds ; 
and, therefore, the inference to be drawn from such cases is, that in 
some persons it is very easy to generate erysipelas de novo, and that 
it is not capable of communication without a certain amount of con- 
centration or intensity of the poison. 

The treatment of erysipelas is simple: it presents the same ques- 
tions for decision, and should be guided by the same principles, as 
that of continued fever. The milder cases require but little treat- 
ment ; attention to the bowels, saline draughts, with the addition of a 
little antimonial wine, will generally be all that is required in the 
way of medicine : the patient should also be kept in bed till the 
inflammation has subsided, and precautions should be used against 
exposure to cold until the desquamation is complete. 

In the severe cases the same treatment should be used at the com- 
mencement : the patient should be put to bed, a gentle aperient, in 
shape either of rhubarb and calomel or hydrarg. cum cret. and castor- 
oil administered, and salines used. The best form will generally be 
the liq. ammon. acet., to which may be added sp. seth. nit., and when 
there is any sharpness of the pulse, a few minims of antimonial wine. 
A question now arises as to any applications to the surface, and vari- 
ous modes of treatment have been recommended : in mild cases the 
best application will be the sprinkling of flour or starch over it ; the 
latter is preferable ; finely-powdered charcoal is, but for its blackness, 
an appropriate application. When the tension is great, especially 
about the face and scalp, the making a large number of minute 
punctures with the point of a lancet, and subsequently fomenting the 
parts so as to encourage the bleeding, is a very useful means of lower- 



TREATMENT. 553 

ing the local inflammation, and often with it the constitutional fever. 
The long incisions which have favour with some practitioners can- 
not, however, be too emphatically condemned; cold applications should 
never he used to erysipelas of the face or scalp, but warm fomentations 
are often soothing when there is much tumefaction of the eyelids. 

As the disease proceeds, the question of the use of stimulants 
becomes the all-important one. In erysipelas we must generally 
endeavour to anticipate the prostration, and as soon as the pulse 
becomes compressible, the sesqui-carbonate of ammonia should be 
added in excess to the amount of about five grains: indeed in this 
disease, like scarlatina, the volatile alkali seems to have a peculiarly 
favourable effect. As the tongue becomes drv and sordes accumu- 
late upon the teeth, wine must be freely administered, as in the low 
forms of other fevers, and the serpentaria or bark should be used for 
the vehicle of the ammonia; a good form is the annexed (F. 96).* 
The bowels should be watched ; they should not be allowed to become 
loaded; and if diarrhoea supervene, which it sometimes does, the 
enema of poppy and starch should be administered. 

Another important question will be the use of opium. "Where 
there is restlessness at the earlier period of the disease, henbane may 
be used freely, and will often be effective, but in the more advanced 
periods, if there be much delirium, it will rarely have any effect : we 
must then have recourse to opium, provided the secretions are toler- 
ably free, the pulse not hard, and the pupil, when we can see it, not 
contracted ; the nearer the character of the delirium approaches to 
that of delirium tremens, the more safely may we use opium or 
morphia. In all questionable cases the latter is to be preferred. 

When signs of phrenitis supervene, which they sometimes do, we 
must first inquire if there has been any retrocession of the eruption, 
about the head particularly ; and if this appears to have been the 
case, we must apply a blister to the back of the neck. In cases 
where the very objectionable practice of applying cold to erysipelas 
on the head has been employed, a blister to the back of the neck 
has in most instances brought back the eruption and saved the 
patient. When the stomach is the organ particularly affected and 
there is obstinate vomiting, a blister or sinapism should be applied 
to the pit of the stomach, and Henry's calcined magnesia may be 
given, to the amount of about ten grains, with about three of dilute 
hydrocyanic acid in an ounce of vehicle ; or if there be much 
depression, the brandy and soda-water, recommended in continued 
fever, may be employed. The erysipelas of new-born children oc- 
curring within the month is always a most dangerous disease, many 
obstetric practitioners regard it as almost certainly fatal. The best 
mode of treatment is warmth, and the use of ammonia. 

In severe cases, where there is no head-affection, the sesquichloride 

* (F. 96) R. Aramon. Sesquicarb. gr. v. 
Tinct. Ciuchonce co. £ iss. 
Decoct. Cinchona), 5 ss. 
Infus. Serpentarise, 5 iv. Misce. 
Ft. liaust. To be given every fourth hour. 



554 YELLOW FEVER. 

of iron; in doses of about ten minims of the tincture three or four 
times a day, appears to be almost a specific. 

[THE YELLOW EEVER. 

The yellow fever is a disease bearing a close resemblance, in many 
of the features of its etiology and symptomatology, to the febrile dis- 
eases' of acknowledged malarial origin, and yet differing from these, as 
well as from all other fevers, in many striking and important parti- 
culars. It would appear to be, in fact, as it has indeed been 
described, by several distinguished physicians, an affection sui generis 
— a specific fever. 

The occurrence of yellow fever is confined, strictly, within a certain 
geographical range, and limited by the atmospherical temperature of 
the climate and season — too great, as well as too low a degree of 
heat appearing to be alike inimical to its production. It is inva- 
riably arrested by the appearance of frost. 

The natives and permanent residents of the localities to which the 
disease is endemic are in a great measure exempt from its attacks, 
as is also the negro race. 

It is a fever of but one single paroxysm, terminating, in the great 
majority of cases, within seventy -two hours, and followed by an entire 
remission^ succeeded either by complete convalescence, or, after longer 
or shorter interval, by a state of exhaustion, and a series of morbid 
phenomena eventuating, most commonly, in death. 

Persons who have once suffered an attack of the fever are gene- 
rally, though not invariably, exempt from a recurrence of the disease 
in future. 

Yellow fever has received a variety of denominations, founded on 
the place from whence the disease is supposed to have been originally 
derived, on one or other of its characteristic symptoms or peculiari- 
ties, or its supposed pathological character. The term yellow fever, 
by which it is know to the large majority of English and American 
physicians, as it involves no hypothetical views in relation to its 
etiology or pathology, is perhaps, in the present state of medical 
opinion, as good a one as can be adopted. It is based upon the 
icteroid hue of the surface by which the disease is usually attended 
in some one or other of its stages. 

In its pathological character, and pathognomonic phenomena, yel- 
low fever is always identically the same disease in whatever locality it 
may appear, as well as during its subsequent recurrences in the same 
locality. Nevertheless, it is liable to assume, in different places, at 
different periods, and often at the same place during the same season, 
various important modifications in its general characteristics — pro- 
ceeding, not from any specific difference in the nature of the disease, 
but from varying degrees of reaction — from a tendency to depression 
in the vital force — from the preponderance of certain symptoms, 
appertaining or not to the disease, and varying according to the 
greater or fewer number of vital organs involved, or from other 
causes ; the whole depending on peculiarity of constitution, tempera- 



DESCRIPTION. 555 

ment, habits, or state of health in those attacked ; on a difference of 
intensity in the morbific agent, and on various contingencies result- 
ing from the nature of the localities at which the disease prevails, the 
degree of temperature, humidity, and other atmospherical phenomena. 

Hence, it follows, that, in the examination of the disease no inva- 
riable concatenation of phenomena, succeeding each other in regular 
order, as the disease progresses towards a favourable or fatal termina- 
tion, are not to be expected in every case. 

"But a variety of groups of symptoms which, though linked 
together by certain phenomena — which, being pathognomonic of the 
disease, approximating to each other in several other respects, afford 
very strong evidence of their being all members of the same family 
— are yet sufficiently distinct in their general outline and their mode 
of progression, to justify their being made the subject of separate 
consideration. Certain of those groups of symptoms, or varieties of 
the same disease, prevail more generally in some regions than in 
others; thy are also more frequently encountered in some seasons 
than in others, in the same place ; while in some epidemics, several or 
all the varieties are intermingled among the different individuals 
attacked ; in others, the fever assumes much the same character in 
the majority of those affected. Such being the case, it is evident that 
the description of the disease as it affects one individual, or one set 
of individuals, will not necessarily apply to another case or group of 
cases. In some, the fever presents itself with marks of inflammatory 
action of greater or less intensity; in others, that action is almost or 
totally absent. In some, the pathognomonic symptoms are combined 
with an element of malignancy and putridity which imparts a totally 
different aspect to the disease. In a different set this element is 
absent, and replaced by one of a nervous character. In some in- 
stances, phenomena not characteristic or pathognomonic of the dis- 
ease, and depending on accidental complications, assume the predo- 
minance, and thereby impart still greater differences in the features 
of the case."* 

To meet these varying characteristics of the diseases at different 
places, and in different seasons, or in different individuals, the dis- 
ease has been divided into various forms. The division of all cases 
into the inflammatory, or those characterised by well marked reaction, 
and the congestive, in which this reaction is but faint or totally absent, 
would seem to be founded in nature. These general forms have been 
again subdivided, the first, into the mild, the violent, and the intense ; 
the second, into the slight, the aggravated and the apoplectic. Under 
one or other of these divisions all the cases of yellow fever that pre- 
sent themselves may be, very conveniently, arranged. 

The attack of yellow fever usually occurs in the after or fore part 
of the day — sometimes during the night. It may commence abruptly 
without premonitory symptoms of any kind. The patient may be 
struck down at once, as by a blow or by lightning, and sink immedi- 
ately into a state of coma. Sometimes the attack is preceded for several 
days by anorexia, general uneasiness, costiveness, flatulence, heat in 

* La Roche on Yellow Fever, Vol. I., p. 1-2. 



556 YELLOW fever/ 

the stomach, lowness of spirits, vertigo, pain of the head, with dull, 
watery, or brilliant, yellow or red eyes, &c. Very generally the 
attack is ushered in by a sense of chilliness, often alternating with 
glowing flushes of heat, or by a regular chill, amounting sometimes 
to a perfect rigor. On the other hand, in even severe and dangerous 
attacks, all symptoms of the kind may be absent. 

The alternation of chilliness and heat is seldom of any duration. 
It soon gives way to confirmed fever, which, though continued, is 
more intense in the latter part of the day and during the night, than 
during the other portion of the twenty-four hours. In the more 
malignant forms of the disease there may occur but a slight reaction, 
or it may be entirely wanting ; the pulse being feeble, soft, occa- 
sionally full, or scarcely to be felt — the patient sinking at once into 
a state of collapse, or of stupor, coma, and convulsions. 

"When febrile reaction becomes fully developed, the pulse is gene- 
rally quick and tense, and during the exacerbation full and strong, 
though, occasionally soft, and from ninety to one hundred and twenty 
in a minute. In very malignant cases it is gaseous. There is a 
violent throbbing and beating of the temporal arteries and carotids. 
The skin is hot, dry, harsh, and pungent, or it may be dry, unctuous, 
or perspiring, flabby and cold, except over the centre of the body. 
The face is either highly flushed, pale, or purplish. The eyes decid- 
edly red, sometimes as though bloodshot, hot, and more or less painful, 
the patient experiencing a sensation as though grit or sand had been 
introduced beneath the eyelids. Often the ball of the eye resembles a 
mass of vessels distended with blood, it is, at the same time brilliant, 
shining, and watery, in some cases presenting somewhat the expres- 
sion peculiar to intoxication. 

Occasionally the condition described continues from the onset of 
the attack to the close of the stage of reaction, or it may only par- 
tially exist during the first or second days. Sometimes profuse per- 
spiration occurs and continues to the second or third day of the 
attack ; at others, the temperature of the surface undergoes but little 
change, at others, again, the skin speedily becomes dry and cool, 
with complete torpor of its vessels, and an entire loss of irritability. 

The symptoms described are very generally attended with more 
or less intense pain, usually of the fore part of the head, and eyes, 
shooting from temple to temple, but occasionally confined to one 
side. This constitutes, in the majority of cases, one of the most dis- 
tressing symptoms throughout the entire stage of reaction. There 
is also pain, often of the most intense character, in the back, loins, 
and large joints — extending to the hips and down the thighs, or even 
lower. Cases occasionally occur, however, in which no such pains 
are experienced, or the pain in the back and limbs is dull and ob- 
scure, or that of the head is replaced by a sense of weight and 
stupefaction 

During this stage, the tongue is moist, covered with a thin, white, 
cottony fur, and most commonly red at the edges and apex ; occa- 
sionally there is a soreness of the throat, sometimes even rendering 
deglutition difficult. 



SYMPTOMS. 557 

At the very onset of the attack nausea or other uneasiness of the 
stomach, with or without vomiting, is not unfrequently present. 
Generally the stomach is distended, often, but not always, painful 
upon pressure, and irritable, especially after taking any kind of drink 
or aliment — frequently affected with a sense of nausea and more or 
less propensity to reject its contents. These gastric symptoms are 
not, however, in general fully developed until from twelve to twenty- 
four hours from the commencement of the attack, or at the commence- 
ment of the second stage, when they become prominent. ■ 

On the first or second day of the attack, sooner or later, the patient 
experiences a burning pain, or a sense of stricture, weight, distension, 
or oppression — sometimes overwhelming — at the prsecorclia, which 
feels as if tightly bound with a cord. Tenderness or pain is expe- 
rienced on pressure in most cases — often excessive. The irritability 
of the stomach augments and proves distressing — every thing swal- 
lowed is rejected, and even when the stomach is undisturbed by drink 
or medicine its morbid contents are thrown off spontaneously — con- 
sisting either of substances that have been swallowed, mixed with 
clear, glazy mucus, or with matter of a sea-green colour and bitter 
taste. In mild cases, bilious vomiting sometimes occurs. The act 
of vomiting is often violent, and attended with retching and con- 
siderable distress and pains. There is, at the same time, conside- 
rable, though not often insatiable thirst. The desire for cold drinks 
is nevertheless generally extreme. 

The urine is commonly deficient in quantity, and of a dark red 
colour; often depositing a copious sediment. The bowels are ordi- 
narily costive — sometimes obstinately so. When stools are obtained 
the discharges are, at first, usually soft and feculent, seldom tinged 
with bile — occasionally they are of a drab colour. "When cathartics 
have not been given, the stools, in the course of the disease, become 
lighter coloured, and assume a starchy, cream-like or puruloid 
appearance, In a few cases they are watery, or even bloody, from 
the outset of the attack. 

The patient is affected with extreme restlessness and jactitation; 
moans, sighs, and shifts his position continually in search of ease. 
In the very few cases in which jactitation is absent, the patient some- 
times feels a disposition to rise from his bed, and walk about the 
room, his muscular strength remaining unimpaired to a degree 
unusual in febrile diseases. There is nevertheless, from the outset 
of the disease, and during its entire course, in numerous instances, 
universal debility. 

In very many cases the patient complains of feeling as though he 
were unable to expand his chest or inflate his lungs. Spasmodic 
pains about the chest are not unfrequent. Respiration in some cases 
is laborious and hurried; in others, slow, and accompanied with deep 
and heavy sighing; in others, again, it is unaffected. 

The blood drawn soon after the onset of the disease, and when there 
are symptoms of well marked reaction, and especially when any local 
inflammation is present, is sometimes of a bright arterial hue. sizy, 
and even cupped, as in ordinary phlegmasia?. In a very large num- 



558 YELLOW FEVEK. 

ber of cases, however, it presents neither cupping or buffy coat, and 
the coagulum is flabby and easily torn. When the separation into 
crassamentum and serum takes place, in some cases the latter is of a 
natural colour ; in others, it is of a yellow hue, or slightly tinged 
with red, and transparent ; in other cases, again — more frequent in 
some epidemics than in others — the separation does not take place, 
the blood remaining for hours, or altogether the same as when first 
drawn. In a few cases, when drawn later in the disease, or throughout 
its course in cases unattended with reaction, the blood is of a dark 
colour, void of all inflammatory indications, and not unfrequently as 
fluid as molasses ; while in other cases, again, it is smeared over 
with a pellicle of sizy lymp, at the same time that the part lying at 
the bottom of the vessel is dissolved. In the early stage of the in- 
flammatory form of yellow fever, the blood is very hot, and has a 
peculiar odour, which, according to some accurate observers, is sup- 
posed to furnish a sure indication of the true nature of the disease. 

At first, the patient attacked with yellow fever, is apprehensive 
and anxious to a distressing degree, as strongly expressed by his 
countenance. In very malignant cases there is an expression of 
apathy or one indicating a sense of horror or intense agony. In 
most cases, there is some confusion of intellect attended with constant 
pervigilium, though without so much derangement of the reasoning 
faculties as to amount to decided delirium. In some cases, however, 
the latter symptom assumes a more marked character, the disturb- 
ance of the mind reaching to the- degree constituting mania, attended 
with wild or fiery looks, and uncontrollable agitation of body. In 
other instances, there is a greater or less degree of stupor, through 
which, as Dr. Wood remarks, when short of coma, the signs of dis- 
tress show themselves as through a veil. In not a few cases, though 
particularly in young persons of both sexes, and in females at two 
different periods of life, hemorrhages take place from one or both 
nostrils, during the afternoon exacerbation. 

The stage of febrile reaction continues with little or no mitigation 
during a period varying from a few hours to two, three, or more 
days — the duration being commonly in inverse ratio to the violence 
of the attack. Having run this course, the fever, with all the attend- 
ing symptoms, subsides, never more, or very seldom, to return — the 
disease being one of a single paroxysm — and is followed by a period 
of remission or metaptosis, during which the several organs of the 
system resume their normal functions. The patient feels himself able 
to set up, or even get out of bed. His eyes and face become tinged 
with yellow, or copious evacuations of bilious matter occur by stool, 
or a gentle or profuse perspiration sets in, or often, without any such 
critical signs, convalescence is established, and the patient speedily 
recovers. 

This, however, is the course only of the most favourable cases. In 
the larger number, the period of remission which follows the first 
stage is only temporary, and is soon succeeded by other phenomena 
of a more formidable character. During the very period of de- 
ceitful calm, symptoms may be. detected, denoting the existence of 



SYMPTOMS. 559 

undiminished danger. The tenderness of the epigastrium is unre- 
lieved or e^en increased; the eyes and face usually acquire a yellow 
or orange colour, which gradually extends from the forehead to the 
face, neck, chest, and, finally, diffuses itself more or less generally 
over the whole surface. The urine also is found tinged with the 
same yellow hue. The pulse is sometimes slower than in health, 
and in bad cases the patient betrays a little heaviness of intellect or 
stupor. 

After a period, varying from a few hours to twenty-four or more, 
the symptoms just enumerated become aggravated, and others are 
added. In the majority of cases, the pulse remains natural, or slower 
than in health, and becomes still slower as the disease advances, until 
at length the pulsations are reduced to forty or thirty in a minute, 
being, at the same time, feeble and irregular. The heart, neverthe- 
less, even in the most malignant cases, often beating with consider- 
able energy, even after the pulse has ceased to be felt at the wrist, &c. 
The tongue becomes loaded — particularly in the centre — moist or 
dry, and with or without redness of the edges. Thirst increases, and 
is often insatiable, — nausea and vomiting, with heat in the stomach, 
return, and become constant, — the matter ejected being mixed with 
streaks or flakes of a red or brownish colour. Respiration quickens, 
or becomes embarrassed — the skin becomes cool, dry, and parched — ■ 
the anxiety at the prascordia is now distressing, and attended with 
a sobbing kind of sighing, constant hiccough, and, occasionally, an 
expression of deep anguish and despair. 

The mind often remains clear and undisturbed. There is generally 
an extraordinary degree of apathy evinced — the countenance present- 
ing an expression of resignation or indifference as to the issue. Some- 
times the patient evinces a kind of cheerful delirium, imagining himself 
well ; in other cases, without delirium, he remains for a long time as 
if in a deep reverie, and when aroused, starts with surprise, and 
answers in a hurried manner. Many, while apparently in great dis- 
tress, declare that they are well. 

As the disease progresses, coma supervenes, from which the patient 
is aroused by vomiting or by dreams, and fancies himself perfectly 
restored to health — attempts to rise, but soon relapses into a state of 
insensibility. In many cases, debility is more or less considerable. 
In not a few, however, the patient retains, to a late period, his mus- 
cular strength — to such an extent, indeed, that he will get out of bed 
and walk about his room, or e^en beyond that, if permitted. The 
physiognomony is peculiar and striking, conveying, as has been well 
remarked, an impression at once of the malignant and dangerous 
nature of the disease. 

Usually the foulness of the tonge increases, though it is not uncom- 
mon for it to become, after a short time, cleaner and moister than 
before. It is sometimes tremulous and protruded with difficulty ; 
when the patient succeeds in showing it, he not unfrequcntly forgets 
to put it in again. It is brown and dry in the centre, or smooth, red 
and chapped, or white at the edges, with a black streak in the mid- 
dle. The gums, lips, teeth and nostrils are covered with sordes. 



560 YELLOW FEVEE. 

As the case advances, the vomiting becomes less frequent, while 
irritability of the stomach, which rejects everything introduced into 
it, continues undiminished. "When vomiting does occur, however, 
there is an increase in the quantity of the matter ejected, and to the 
momentary relief of the patient. The matters ejected from the 
stomach are often thrown out forcibly and to a considerable dis- 
tance. 

From the condition just described, recovery not unfrequently takes 
place — generally by a gradual receding of the symptoms, but some- 
times by an evident-critical revolution — the pulse acquiring force and 
activity, the skin becoming warm and moist, the irritability of the 
stomach lessening and finally disappearing. 

In other cases the symptoms are of a still more formidable char- 
acter. The matter thrown up by vomiting consists of brown, black- 
ish, or chocolate flakes or particles, diffused in a colourless liquid, 
which, though at first slightly tinged by them, ultimately becomes 
black and opaque, resembling coffee grounds floating in a serous 
fluid. In some cases, grumous dissolved blood is thrown up. The 
matter vomited is acrid, often excoriating the throat, tongue and lips. 
Although fatal cases of yellow fever may occur unattended with 
vomiting of black matter, it is a common attendant upon the disease 
at the period indicated, and always portends the most imminent dan- 
ger, for, though some recover after its occurrence, the number is very 
limited. The abdomen is soft, seldom meteorised. The stools, when 
they occur, present the same character as the matter ejected from the 
stomach, or resemble tar or molasses, or they may consist of blood, 
more or less pure. The urine becomes natural in appearance, or of 
a dark colour, and limpid. It is often suppressed from deficiency of 
secretion, or simply retained. Sleep is interrupted, and attended 
generally with painful dreams. The face and breast become spotted 
as with ink. The jaundice — which though so common an attendant of 
the disease as to have given it its name, is nevertheless often, especialy 
in rapid cases, totally absent — becomes more diffused and of a deeper 
hue. The skin assuming often a deep, dusky yellow, or brown, ma- 
hogany, bronze or purple hue, imparting the idea of blood settled in 
a bruised part. The blood in the capillaries becomes stagnant, form- 
ing petechia?, vibices, or large blotches, and accumulates in depend 
ing parts, and the extremities. In many cases it oozes from the nos- 
trils, tongue, gums, anus, eyes — from leech bites, blistered surfaces, 
and the punctures of the veins, and is, like all the blood in the 
vessels, dark coloured and dissolved. 

As the disease advances, these symptoms increase in intensity; 
hiccough sets in, and is soon constant and accompanied with the hip- 
pocratic countenance, difficulty of swallowing and slow and stertorous 
convulsive respiration. The pulse becomes small, feeble, intermittent, 
and finally fades away. The alvine evacuations are highly offensive, 
of a cadaverous smell, and, like the urine — which, if at all secreted, 
assumes a blackish and bloody appearance— are avoided involun- 
tarily. Subsultus tenclinum not unfrequently follows ; so also gan- 
grenous spots, and, in a few cases, buboes, carbuncles, and eschars in 



SYMPTOMS. 561 

various parts of the body Loss of speech, dimness of vision, insen- 
sibilitv, low muttering delirium, and coma, at times supervene ; but 
it is not unusual to find patients retaining their intellectual faculties 
unimpaired to the last. Rattling in the throat, cold clammy sweats, 
cadaverous and peculiarly offensive odour of body, cold respiration, 
are the immediate precursors of death, which often occurs quietly, 
but, in other instances, in the midst of violent convulsions. 

The duration of the disease varies, according to the nature of the 
case, from three to nine days; sometimes it is shorter, at others 
longer; while, in cases of recovery, the convalescence is usually 
secure and rapid. 

In the foregoing account of the symptoms of yellow fever, considered 
in the aggregate, without reference to the particular groups in which 
they may present themselves, in the slight ephemeral to the most 
intense inflammatory grade, and in the several grades of the conges- 
tive form, we have followed very closely the admirable delineation 
of the disease given by Dr. La Roche in his late invaluable treatise 
on the yellow fever, using frequently his very words. 

Following the author just referred to — and we know of no better 
guide — we shall now rapidly sketch the features of the disease as 
exhibited in the several grades of its inflammatory and congestive 
fevers. 

In the more intense grade of the inflammatory form, we have the 
initiatory chill — of a more or less decided character, followed by 
intense febrile action — a quick, frequent, strong and full pulse; hot, 
and usually dry, parched, skin; violent throbbing of the temporal 
and carotid arteries; flushed face; red, blood-shot, brilliant, shining, 
watery eyes, with a sense of pain or soreness in the balls ; sometimes 
tumid eyelids; intense pain in the supraorbital region, in the back, 
thighs, and legs ; tongue usually crimson red at its edges and apex, and 
covered with white or yellow fur; a sense of anxiety, constriction 
and intense pain at the prsecordia; nausea, succeeded by retching 
and vomiting, at first of the matters swallowed, mixed with a clear, 
glairy mucus — occasionally with a sea-green coloured substance of a 
bitter taste — now and then of pure bile — often distension of stomach, 
which is sometimes painful on pressure, and generally irritable to an 
extreme degree, especially after the first twelve or twenty-four hours 
of the attack. The urine is deficient in quantity, high coloured and 
often sedimentitious. There is obstinate costiveness — the stools, 
when obtained, being at first soft and feculent, sometimes tinged 
with bile; when no cathartics are used, they become, subsequently, 
lighter coloured and of a starchy, cream-like appearance. There are 
considerable jactitation and restlessness, with moaning and sighing 
— and a disposition to rise from bed and walk about. The respira- 
tion is laborious and hurried. There is an anxious, gloomy, sad, or 
impatient expression of countenance. The patient experiences great 
apprehension— there is confusion of intellect, constant sleeplessness. 
Delirium, properly speaking, is generally absent; occasionally, how- 
ever, it is present, even from an early period of the attack, reaching 
sometimes to a degree amounting to actual mania 

36 



562 YELLOW FEVER. 

The stage of reaction lasts from a few hours, to two, three or more 
days — generally from sixty to seventy-two hours. It is succeeded by 
a remission of all the symptoms. The patient becomes at once cheer- 
ful, sits up or gets out of bed, and expresses a desire for food. The 
adnata of the eyes now usually assume a yelloAvish tinge. 

The remission, which is too generally a deceitful calm, may con- 
tinue from a few hours to twenty -four or thirty, and then gradually 
glide into the second stage. Prostration follows; the pulse be- 
comes rapid, irregular and depressed, or more generally, it is natural 
in frequency or even slower than in health. The tongue becomes 
loaded with a brown fur, having a darker streak along its middle, 
swollen, and moist, or, frequently, it is clean, with a slight pasty coat- 
ing, or it may be of a deep fiery red, and, occasionally, in an ad- 
vanced period, it is bloody, or dry, black, aud chapped ; with dark 
coloured sordes on the mouth, lips, gums, and nostrils. The respi- 
ration is quick and laborious; there is augmented and insatiable 
thirst; a distressing sense of anxiety at the preecordia, accompanied, 
often, with hiccough and sighing. There is an augmentation, in 
many cases to an intolerable degree, of the pain at the epigastrium, 
which is aggravated during the vomiting; that now occurs almost 
spontaneously — the contents of the stomach being forcibly ejected 
and to some distance — the matters discharged consist of brown, black- 
ish, or chocolate flakes or particles, diffused in a colourless fluid, and 
gradually acquire, in fatal cases, the characteristics of black vomit. 
Occasionally, involuntary discharges occur from the bowels of a black, 
acrid, offensive matter, sometimes resembling tar or molasses, at 
others the stools consist of blood. A yellow tinge, which appeared 
at first about the forehead and eyes, extends, subsequently, to the 
face, chest, and, finally, over the entire surface, gradually acquiring 
a deeper hue, the skin assuming a dusky, brown, mahogany, or 
bronze colour. The jaundiced hue of the skin is sometimes, how- 
ever, absent, or restricted to the adnata of the eyes, or appears only 
after death. The mind is often clear and undisturbed to the last — 
frequently the patient exhibits a degree of apathy, with an expres- 
sion of resignation and indifference. In other cases various modifl- 
cations of delirium are present. Frequently, there is more or less 
debility ; in perhaps the majority of cases, however, the patient re- 
gains his muscular strength, if he had previously lost it, and retains 
it to the last. The body, in the progress of the disease, becomes cold 
and clammy ; the urine blackish or bloody, and is often passed in- 
voluntarily ; more generally it is suppressed or retained. Hemorr- 
hages of dark, dissolved blood, occur from all the natural outlets, and 
death, preceded by intolerance of light, petechias, meteorism, singul- 
tus, eructation of offensive gas, subsultus tendinum, convulsions or 
coma, closes the scene. 

The rapidity of the fatal termination in this grade, is, in general 
proportioned to the violence of the inflammatory action of the second 
state, by which, in its higher degree, the vital organs may become 
rapidly overwhelmed and disorganised, to a degree incompatible 
with the continuance of their functions. Eecoveries seldom occur in 



GKADES OF THE DISEASE. 563 

this form and grade of the disease ; when they do, it is by a gradual 
amendment of the symptoms, or some critical movement taking place 
before the accession of black vomit. 

In the milder grade of the inflammatory form, the symptoms of 
the first stasre are nrettv much the same as in the morefintense grade, 
but less violent, rapid, and tumultuous. It is attended by more 
decided exacerbations and abatement of the fever — the abatement 
often approaches to an actual remission. It often extends to four or 
five days. The second period or that of remission is more perfect, 
and in many cases the harbinger of recovery — convalescence dating 
from the final subsidence of the fever — the disease terminating with 
bilious critical discharges by the bowels, a moisture over the skin, or 
diaphoresis, a copious emission of urine, or a hemorrhage from the 
nose — with or without jaundice — often without any evident crisis. 

In other cases, however, the remission is followed by many of the 
symptoms which mark the second stage of the preceding grade. These 
sometimes assume a character of great malignancy, and if not ar- 
rested by art, or the recuperative efforts of nature, terminate in death. 
In other cases, they stop short of black vomit, and the patient is gra- 
dually restored to health. In others again, though in a very small 
number, recovery ensues, even after the supervention of the black 
vomit, and other usually fatal symptoms. The disease in this grade 
is evidently of a less malignant character, and within the range of re- 
medial agencies. The bowels are acted upon w ithout much difficulty 
by cathartics or enemata, the operation of which is productive of re- 
lief, the pain and affection of the head and other parts are under the 
control of proper depleting remedies, general and local, revulsives, 
&c; the gastric irritability, though obstinate, is not always as un- 
controllable as in the more intense grade, and diaphoresis is generally 
easily obtained by external and internal means. 

In the ephemeral grade of the inflammatory form, although there 
are the same general features, the same outline of phenomena, as 
characterise the preceding grades, they are of a still milder and more 
manageable nature — and terminate, under proper and even mild 
treatment, sometimes in a single day. Occasionally, however, it 
continues from three to five days, when, in some cases, it is attended 
with slight and imperfect remissions. 

The symptoms indicative of an open and well developed febrile 
paroxysm subside, sometimes, suddenly ; at others, the crisis being 
marked by increased alvine evacuations, by diaphoresis, or epistaxis. 

In the aggravated grade of the congestive form, the attack occurs 
suddenly. From the outset there is considerable prostration. In 
most cases, from an early period, there is giddiness, stupor, almost 
unconquerable disposition to sleep, loss of memory, and a desire to 
be left alone. There is a sense of weight and oppression, rather 
than of acute pain in the head. In a few cases, there is delirium, 
either transient, or ending in confirmed coma. The face is pale. 
purplish, or livid in color, with a stolid or apathetic expression of 
countenance — the patient being taciturn, and uttering no complaint. 
Sometimes there is entire insensibility, the eyes being wide open, at 



564c YELLOW FEVER. 

others there is an expression indicative of distress, horror, or even 
intense asrony. 

There are obscure pains of the loins and extremities, and a feeling 
of helpless debility about the spine— most distressing at the sacrum — 
sometimes attended with a paralytic failure of the lower extremities. 
There is a dull, red, glassy, or drunken, idiotic look of the eyes, 
with, in some cases, a dilatation of the pupils, and sleepy movement. 
The skin is always deficient in tone, dry, dense, or unctuous, or 
sometimes covered with, and as if melting in sweat. It is generally 
cool — sometimes cold, except at the central portion of the body, 
which is hot ; in some instances it is smooth and white, and occa- 
sionally loses, more or less completely, its sensibility and irritability. 
The pulse is sometimes accelerated, at others not more frequent than 
in health ; sometimes full, at others small. It is always weak, 
offering no resistance to the pressure of the finger ; occasionally it 
is scarcely perceptible at the wrist, though at the same time the 
heart and carotids may be throbbing forcibly. As the disease 
advances, it diminishes in frequency, the beats not amounting, at 
times, to more than fortv, or even thirtv in a minute. In some 
cases it becomes intermittent. When blood is drawn, it is generally 
found black or discoloured, and seldom retains its natural character. 

There is tenderness of the epigastrium, tension of the hypochon- 
dria, weight and oppression at the praecordia. There is early irrita- 
bility of the stomach — and vomiting — the matter ejected rapidly 
assuming the character of black vomit. The discharges from the 
bowels are scanty — cream or cla}^-coloured, puruloid, or gelatinous 
— sometimes of a pea-green colour, or black and bloody. The respi- 
ration is laborious. The tongue, sometimes natural, is at others, 
first pasty, with patches of white fur ; its edges and apex being red. 
Occasionally, it appears as though seared with a hot iron. It is 
often tremulous, and when the patient puts it out he often forgets 
to draw it in again. It sometimes becomes dry, while the papillae 
are separated by deep fissures. There are, also, orthopnoea, sore 
throat, deep and interrupted sighs, haemorrhages of dissolved blood 
from one or more of the natural outlets, a yellow or bronze colon 
of the skin, suppression of urine, extreme restlessness, low, mono- 
tonous wailing, and other symptoms indicative of the utmost danger, 
or the approach of death. 

In some cases, the leading symptom is an overwhelming oppres- 
sion at the prascordia, attended with slow, laboured respiration, deep 
sighs, and groans. In others, constant vomiting, and intense epigas- 
tric distress, quickly followed by black vomit and death ; in other 
cases, again, the pulse is nearly natural, the tongue clean, and the 
stomach calm, but excessive restlessness, anxiety and distress ensue, 
soon followed by black vomit and fatal collapse. 

In some instances, the disease, though marked by the same train 
of phenomena, assumes, nevertheless, in its course, a less formidable 
character, stops short of the black vomit and other fatal symptoms, 
and proves comparatively mild and manageable. As a general 



GEADES OF THE DISEASE. 565 

rule, however, but very few of those attacked with this form of the 
disease recover. 

The adynamic or typhoid grade occurs in persons deficient in 
vital power, or under circumstances tending to foster or develope 
the typhoid diathesis. It is generally ushered in by a sense of 
chilliness, succeeded by one of burning heat, partially distributed 
over the body — affecting principally the under parts of the arms, 
and inner surface of the thighs. The circulation is depressed, the 
pulse being small and weak. The eyes have a dingy appearance. 
The head is severely painful, with confusion of thought and dimness 
of vision. The skin assumes an olive hue, and is covered with 
petechias or vibices. Haemorrhage from the natural outlets, leech 
bites, &c, follow, as also excoriations about the nose, mouth, or 
other parts ; gangrene of blistered surfaces, sometimes anthrax, 
buboes, and, more frequently, venous infiltration under the skin, or 
in the interstices of the muscles. 

The w alking grade of yellow fever is so named from the fact that 
in it the organs of animal life remain almost unaffected. The 
patient most frequently sauntering about his room, or, at times, 
even walking in the streets for recreation or on business. In some 
instances he acknowledges to a feeling of weakness, but, in others, 
he exhibits at intervals, or throughout, indications of considerable 
muscular strength. He complains of nothing, denies his being ill, 
amuses himself in reading or otherwise, and to a casual observer, 
appears to be slightly, if at all, indisposed. The physician will be 
able, however, generally to observe that the patient exhibits an 
unusual expression of countenance — dull and listless. The eye is 
watery — the complexion almost of a mahogany hue — the pulse 
exceedingly weak, or even totally absent. Black vomit overtakes 
him, even while occupied as described, or very soon after, and death 
speedily ensues. 

In some of the cases of the apoplectic grade, the patient is struck 
down suddenly, as if by lightning, with stupor or coma, and death, 
preceded by convulsions, soon follows : or, without the slightest 
prernpnition, he is instantly seized with vertigo and confusion of 
mind ; accompanied with dull pain and fulness in the head — spas- 
modic pain and considerable debilhVy in the legs — coldness, debility, 
and a sense of uneasiness in the spinal region — a pulse varying, 
in different cases, in fulness and frequenc}^, but always weak, and 
finally faltering, — a cold skin, sometimes dry and flabby, but gene- 
rally unctious or bedewed with cold perspiration — and irritability of 
stomach. The patient lies as if stunned, with dilated pupils and 
an expression of gloom on his countenance. An effort at reaction 
occasionally takes place — but scarcely ever leads to a favourable 
result. More generally, the patient becomes perfectly comatose, the 
eyes assume a glassy appearance, the pulse fades away, involuntary 
discharges and profuse haemorrhage supervene, and death soon 



ensues* 



* La Roche on Yellow Fever, Vol. 1., p. 129, ct seq. 



566 YELLOW FEYEE. 

" The yellow fever is far from pursuing, always, everywhere, and 
under all circumstances, the even tenor of its course, without expe- 
riencing more or less important modifications from other causes 
which may operate on the system in conjunction with, or antece- 
dently to, that by which it is produced ; while the special morbid 
agent which gives rise to it, seldom fails to modify, to some extent — 
when it prevails extensively and with great virulence — other dis- 
eases arising from the impress of other causes. Hence arise, on the 
one hand, numerous complications of the fever with complaints of 
various kinds ; in other words, cases in which, to the symptoms of 
the fever, are added others indicating the coexistence of some other 
disease, which owes its origin to the operation of distinct causes ; 
and, on the other hand, those modifications of prevailing complaints 
occasioned by an impress of the yellow fever cause, which, though 
not sufficiently powerful to produce the fever to its full extent, is 
enough so to stamp those complaints with some of its features, and, 
in the language of Dr. Rush, to make them wear its livery."* 

In proceeding to consider the pathological anatomy of yellow 
fever, we may remark in the outset, that cases occasionally present 
themselves, especially when the disease has proved suddenly fatal or 
run a very rapid course, in which no appreciable lesion in any of 
the organs or tissues can be discovered on dissection, or lesions of 
too slight a character to permit us to refer to them any agency in 
the production of the phenomena of the disease, or its fatal termi- 
nation. In the great majority of cases, however, morbid changes, 
often considerable, are to be detected, by which the disease can 
usually be identified, while they throw more or less light on its 
pathology. 

The surface of the body in general presents a yellow colour, 
varying from a pale to a dark orange or brown. In many cases it 
has a greenish, or mahogany, or leaden hue, or even a purple or 
black aspect. The lighter shades of coloration, are usually observed 
in subjects carried off rapidly and by an inflammatory attack, the 
others in such as have fallen victims to attacks of a malignant or 
protracted character. Sometimes a pale yellow line, mingling with 
the other colours, can be traced from the nose to the pubes. The 
discoloration may be confined to the face or eyes, neck or chest, or 
extend over the entire surface. It is generally deeper on the face 
and trunk than on the extremities. It is more intense and general 
after than before death ; it may even not have appeared previously. 

The scrotum, penis, fingers, toes, and ears, which, especially a 
short period before dissolution, are often very much discoloured 
from stagnation of blood, become, as do also the back and neck, of 
a dark purplish hue. These are cadaveric effects. Ecchymoses, 
in spots of different sizes or shape, round or in stripes, sometimes 
occupy the forehead, upper portion of the face, as also the trunk 
and extremities. These latter are the results of disease, and appear 
before death. The surface is, sometimes, also covered with minute 

* La Roche, op. citat. 



PATHOLOGICAL ANATOMY. 567 

ecchymoidal spots, bearing some analogy to petechias, and increasing 
in number after death. 

In many cases the cellular membrane and fat are found to partake 
of the yellow colour of the skin. This occurs less frequently in 
malignant and congestive, than in ordinary cases of the disease. 

Extravasations of blood in the subcutaneous cellular membrane 
and between the interstices of the muscles, are not uncommon. 

In some cases, livid and gangrenous spots occur on portions of 
the body. 

The joints and muscles are generally rigid and stiff; and the latter, 
in those who have died of the malignant form of the disease are often 
of a dusky or dark hue. They are generally softened in texture and 
easily torn or broken down by pressure. Sometimes, especially after 
ordinary and inflammatory cases, they are but little, if at all changed 
in colour and firmness. They are occasionally pale as if they had 
been submitted to prolonged maceration. 

The face, in some cases, is tumefied, in others shrunken. 

The brain is often found entirely free from diseased changes. 
Traces of inflammation are occasionally, however, detected in it or 
its membranes, but have no direct relationship to the yellow fever. 
In many cases, the pericranium, the sinuses, and the vessels of the 
brain are more or less gorged or congested with blood. In some the 
membranes alone, or together with the brain, are injected throughout 
or in patches ; and in many, a fluid of a limpid or yellow colour, or 
mixed with blood, is effused in the ventricles, at the basis, or on the 
surface of the brain, or in its membranes. 

Nearly the same remarks may be made in reference to the lesions 
detected in the spinal marrow. When unequivocal traces of inflam- 
mation of this part or its membranes are present, these must be 
referred to some accidental complication, and not as forming an 
essential part of the disease. Many of the changes met with in the 
spinal marrow after yellow fever, are probably to be referred to 
mere congestion, and the hasmorrhagic tendency which constitutes a 
main characteristic of the disease. 

Various morbid appearances of the ganglia and ganglionic nerves 
have been described as occasionally met with after yellow fever. No 
one of these are invariably present — all of them are frequently absent 
— they often exist in subjects who have died of diseases having not 
the least resemblance to yellow fever ; hence when present they 
are not to be viewed as among the true anatomical characters of the 
latter. 

In general, the respiratory organs present no appearances indi- 
cating that they partake largely and necessarily in the diseased 
action of the system in yellow fever. The lungs are often found, at 
their posterior or lower portions, more or less gorged with dark 
coloured and altered blood. They are frequently in parts or through- 
out, black, resembling a sponge; in substance sometimes firm and 
dense, not unlike the substance of the spleen, or gorged with blood, 
black and dissolved, and do not collapse upon the removal of the 
sternum. Not unfrequently their surface is covered with melaenic 



568 YELLOW FEVER. 

patches or ecchynioses of from two to five lines diameter, or masses 
of a black colour, impermeable to the air. 

The bronchial mucous membrane is in general free from disease ; 
sometimes it is injected, or spotted with blood or even inflamed. 
The pleura is usually unaltered, the ecchymoid spots noticed upon 
it being situated in the cellular membrane beneath, or in the sub- 
stance of the lungs. In some cases the pleura has been found 
inflamed, or containing more or less effused serum of a yellowish, 
orange, or reddish colour, with or without marks of inflammation. 
In a few, the fluid is of a sanguinolent character, and resembles, 
more or less closely, the black vomit. 

The substance of the heart, like that of other muscles, is sometimes 
of a dusky colour, and soft and more flabby than natural, and easily 
broken down by pressure between the fingers. In perhaps the 
greater number of instances, however, the organ retains its natural 
appearance. The pericardium, which generally appears healthy, 
sometimes contains a notable, though not unusual quantity of serous 
fluid of a yellow or reddish colour. The endocardium, in some cases, 
is slightly red, apparently the effect of staining. In many others it 
is, as all the fibrous parts, the valves, &c, of a yellowish colour, which 
often extends into the aorta and the larger vessels. On the surface 
of the former, spots closely resembling petechia?, are sometimes ob- 
served. The cavities of the heart contain a greater or less quantity 
of blood, usually dark coloured, and for the most part grumous 
or fluid, with or without coagula of the same colour. In a large 
number of cases these cavities — especially the ventricles — contain 
albuminous concretions, varying in size and consistency, and of a 
transparent yellow colour, having the appearance of meat-jelly or fine 
amber. They penetrate sometimes into the aorta. 

The stomach is the organ most generally and seriously implicated 
in yellow fever — in it indications of disease are most frequently dis- 
covered after death. Externally it is sometimes of a yellow colour, 
but generally retains its normal appearance. It is usually found to 
contain more or less of matter similar in appearance to the black 
matter thrown up by vomiting in the latter stages of the disease. 
This matter has been shown by recent investigations to be blood — 
most probably diseased in character — poured out by the capillary 
vessels of the digestive mucous membrane, and still further changed 
by the action of the acid it meets with in the cavity of the stomach. 
In some cases, the contents of the stomach consist of blood more or 
less pure, with or without coagula, and generally combined with a 
portion of glairy matter, and substances swallowed a short time 
before death. In some instances, the mucous coat is smeared over 
with a dark, adhesive jelly-like substance, containing portions of 
blood. Under this substance, and sometimes when it does not exist, 
we find a la}^er of grayish matter not unlike a mixture of linseed 
meal. In a certain number of cases, the mucous coat, when cleansed 
from these various coatings, is found to present a normal appearance. 
In many instances it is even whiter than in its normal state, from the 



PATHOLOGICAL ANATOMY. 569 

effusion from its vessels, in all probability, of the blood with which 
thev had been loaded, in the form of black vomit. 

In the greater number of instances, however, the mucous membrane 

O 7 7 

of the stomach is found more or less diseased, indicating that it had 
been the seat of inflamation more or less extended and of different 
grades of intensity. Thus the stomach is sometimes contracted, at 
others distended. The longitudinal rugae are enlarged. The sur- 
face has often a vermicular appearance, being corrugated and thrown 
into numerous folds. Its capillary vessels are injected to a greater 
or less extent with blood. It is reddened, presenting various shades, 
from a rose to an intense dark hue, or it may be leaden, livid, or 
even nearly black. The discolouration being either uniform in ap- 
pearance or in the form of arborisations — it may extend over the 
greater portion of the mucous coat, or be confined to the cardiac or 
pyloric orifices, and large curvature, presenting itself in patches dif- 
ferent in number and size in different cases. Streaks or spots of a 
purple colour, spread in various directions over both the altered and 
healthy parts. The spots, differing in size, have the appearance of 
ecchymoses. At other times, with or without these, there are nu- 
merous small, dark red, or violet round spots, resembling petechias, 
contrasting very decidedly with the rose hue of the mucous mem- 
brane upon which they are scattered. The lining membrane may, 
besides, present abrasions, or small depressions or pits, like holes or 
furrows, as though a portion of the tissue had been removed. It is 
frequently mammilated even to a remarkable degree, also, more or 
less considerably thickened and opaque. It is sometimes softened, 
and easily detached, especially about the great cul-de-sac. In a few 
cases it is ulcerated, or presents a gangrenous change. Sometimes, 
more especially after malignant or congestive attacks, an effusion is 
discovered under the mucous tissue. 

" These changes are not all found in the same cases, nor are they 
present at whatever period of the disease the patient may have suc- 
cumbed, or whatever may have been the character and duration of 
the disease. In congestive or malignant cases, we find more or less 
injection of the capillaries — the redness generally of a dark hue. 
There are usually ecchymoses, and petechias, but no thickening, 
softening, or similar changes. These, together with' capillary injec- 
tion, are, as a general rule, met with after attacks of a different char- 
acter. In these, if death takes place on the second, third, or fourth 
day, the increased vascularity is noticed in bright red or dark, dusky 
patches, more generally confined to the vicinity of the orifices, but 
sometimes extending to the greater part of the membrane. If the 
case has been protracted to a later period — to the sixth, seventh, 
eighth, or ninth day — a larger portion of the surface is found in- 
volved, and we may expect to find it of a leaden, livid, greenish, or 
mottled appearance, and presenting the marks of disorganisation al- 
ready noticed. In instances unattended with these changes, in which 
there is mere redness, with ecchymoid and petechial spots, these are 
probably not the effect of cadaveric changes for they are found im- 
mediately after death, and too soon to be attributed to such cause. 



570 YELLOW FEVEE. 

they must rather be referred to simple congestion. But whenever 
this redness is attended with thickening, or softening, or the mam- 
milated appearance of the membrane, we cannot but join in opinion 
with Louis in attributing these changes to an inflammatory condi- 
tion of the parts."* The appearances discovered in the oeso- 
phagus and intestines do not differ materially from those exhibited 
by the stomach. The intestines when the case has been rapid 
contain often bilious, yellow or ordinary excrementitial matter 
— at other times their contents are brown, black, thick or jelly- 
like, often of a tar-like appearance — or they may be fluid, of a red- 
dish or soot colour, or even consist of blood, more or less pure. 
Sometimes they are whitish, and often present the characteristics 
of the black vomit. The intestines, in a few instances, are con- 
tracted to a greater or less degree, and with more or less force. 
Extensive invaginations are occasionally observed. The duo- 
denum and upper portions of the jejunum are the parts most gene- 
rally affected, though in other cases, the lower portions of the ileum 
are more implicated than the latter. 

The glands of the intestines, especially those of Brunner, are occa- 
sionally found in a diseased or abnormal condition. 

The gall bladder is either empty, diminished in size — withered, as 
it were, or distended, with its usual amount of bile more or less natu- 
ral in quality — or its contents may be small in quantity, viscid, 
inspissated, or mixed with more mucus than common. It is either 
dark green, blackish-brown, or of an obscure red color, and of the con- 
sistence of tar. Not unfrequently the gall-bladder contains a quan- 
tity of thick viscous blood, grumous, tar-like, or ink-coloured, or of 
serum, and more rarely of pus. Its internal membrane is often 
spotted, or punctated, and sometimes largely injected with blood of a 
bright or obscure red or brown, or even dark colour. It is said often 
to present traces of unequivocal inflammation. 

The liver is usually of a light yellow, nankeen, fresh butter, straw, 
coffee and milk, gum yellow, buff, gamboge, light orange, or pista- 
chio colour. In some cases, this discolouration occupies the whole 
surface and pervades the entire parenchyma of the organ ; while, 
again, in others, it extends only partially over both, giving a marbled 
appearance — presenting throughout patches or regular stria3, and 
alternating with others of a dark green colour. It is limited occa- 
sionally to a single lobe, usually the left. Recent observations would 
seem to show that this discoloration is due to a fatty degeneration of 
the organ. 

"Frequently, however, as this peculiar coloration of the liver has 
been observed, it is far from being universally so ; cases occurring in 
which the organ is found of a different hue — dark yellow, brown, red, 
purple, bluish, slate, chocolate, or livid. It has been described as of 
a brick colour, and compared to rhubarb, or to Peruvian bark. In 
other cases, again, it retains its natural appearance externally and 
internally, and is otherwise healthy. The parenchyma, when divided, 
is often found hard, dry, tough, and sometimes dry and brittle, and 

* La Roche on Yellow Fever. I. p. 398. 



CAUSES. 571 

more or less devoid of blood ; while, in some cases, the viscus is more 
or less gorged with blood, and softer in texture than natural. In 
some cases, the biliary pores contain bile, but more frequently there 
is no indication of biliary secretion."* 

Though often more or less enlarged, and at other times shrunken, 
the liver seldom exhibits traces of inflammation, and, if these are dis- 
covered, they must be viewed simply as the effect of complications ; 
while the alteration in, or suppression of, the secretory function of 
that organ, may justly be referred to some cause different from that 
morbid state. 

The kidneys are not unfrequently found in a normal state, or with 
only trifling marks of having partaken of the disease. In other cases 
they are congested — filled, more or less, like other organs, with dark 
fluid blood, the mucous membrane of the pelvis and infundibulum 
being sometimes minutely spotted with blood, or ecchymoses ; or 
they exhibit a morbid state, similar to that observed in B right's dis- 
ease. In other cases they bear the marks of acute inflammation. 

The bladder is often contracted ; sometimes its coats are thickened. 
The mucous coat is generally healthy, or only injected and dotted 
with small points, or ecchymosed. In some cases it is covered with 
a yellow mucus. The bladder is often empty, or nearly so — it may, 
however, contain more or less urine, natural in appearance, bloody, 
or more or less bloody. Occasionally it contains black matter resem- 
bling that ejected from the stomach, or pure blood. 

The spleen is usually of a darker color than natural — sometimes 
somewhat enlarged, and friable. It is often moderately softened, and 
generally engorged with dark currant-jelly-like blood. In some 
cases it is found unchanged. 

No prominent change has been detected in the pancreas. 

In some cases the penis is found covered with eschars ; and the 
scrotum swollen and thickened — brown or black, as in senile gan- 
grene — sometimes with excoriations.f 

The yellow fever is a disease of hot climates and hot seasons. In 
every locality where the disease prevails as an endemic, or in an 
epidemic form, the thermometer gives us an average heat of 80°, or 
thereabouts. In all these places, the disease shows itself only at the 
period of the year when the heat is greatest — and usually with the 
most severity during seasons of the highest temperature, seldom 
attaining its greatest degree of intensity before the heat has continued 
at its maximum average for some time. Heat alone, however, is 
insufficient to produce the disease, for in climates and seasons of a 
higher and longer continued average temperature than that given 
above, it has not made its appearance. 

An excess or at least a certain degree of atmospherical humidity 
would also appear to be necessary to the development of yellow fever. 
The disease frequently occurs during rainy seasons, and is, ordinarily, 
encountered in damp localities, where rain is common and falls abund- 
antly ; where the soil, previously dry, has been rendered wet by copious 

*La Koche, on Yellow Fever. Vol. 1, p, 402. f Ibid. p. 386. ct seq. 



572 YELLOW FEVER. 

rain, freshets, overflows, etc., or where the dew point is high, and 
vesicular humidity generally or often noticed, or is considerable at 
the time. Bat facts innumerable go to show that humidity combined 
with heat, is not sufficient alone, for the production of fever. 

Some local cause capable, when acted upon by heat, moisture, and 
perhaps other conditions of the atmosphere, the exact character and 
influence of which have not as yet been fully observed, of generating 
a special poison — by which an infection of the surrounding atmosphere 
is produced ; which infected atmosphere when taken into the system — 
particularly in one especially predisposed to its morbific influence — the 
poison it contains enters the blood and is by it distributed throughout 
the body — impairing the vital properties of the blood itself, and pro- 
ducing a morbid impression upon the nervous centres — and in this 
manner deranging the functions of, and producing the morbid conditions 
which we detect in the several organs and tissues of the body. The 
variation in the character and extent of these lesions in different sub- 
jects depending on the difference of age, habits of body, and numerous 
other circumstances connected with the individual, on the degree and 
concentration and violence of the efficient cause ; on the peculiar 
character of the epidemic constitution of the atmosphere, on the 
nature of the localities and numerous other modifying agencies. 

It would be impossible to enter here into the evidence of the 
invariable origin of yellow fever from a specific poison existing in 
the air of the localities where it prevails, and produced from causes 
there existing. That evidence is in our opinion conclusive, and 
irrefutable. 

In referring the production of the yellow fever, in every instance 
to a local malarial cause, we mean, also, to deny its propagation by 
contagion ; — we are acquainted with no other disease of a strictly 
local origin ever evincing a contagious character or assuming such 
a character under any possible contingency. The facts, in evidence 
of the non-contagious character of yellow fever, are well authenti- 
cated and numerous — and sufficiently establish the correctness of 
the position. As a general rule,' we use the words of Dr. La Eoche, 
the disease may be regarded as one of low, flat, and level localities, 
and as appertaining more especially to hot latitudes. It never shows 
itself beyond a certain elevation, the limits of its altitudinal zone 
being even more restricted than those of ordinary paludial fevers. 

'" The inability of the yellow fever to be generated at a high ele- 
vation above the level of the sea, depends in part on the greater 
elasticity and purity of the air, on a diminution of atmospheric 
pressure, and on a more thorough ventilation. But the main cause 
is the absence there of the degree of atmospheric heat, which, as we 
have seen, is indispensably necessary for the elaboration of the 
morbific agent to which the disease is due. For the same reason, 
in part, though not exclusively, its geographical limits are restricted 
within certain bounds in a northern direction, while, in a southern, 
the same effects are produced, as it would seem, by an excess of 
heat, and a variety of influences of a meteorological and telluric 
nature. Be the causes, however, what they may, on one point there 



GEOGRAPHICAL RANGE. 573 

can be no cloubt— tliat the yellow fever has geographical limits, 
beyond which it does not appear — and that within those very limits 
there are many places where its usual apparent cause would seem to 
exist, but where, nevertheless, it has never shown itself, or has done 
so very seldom. The West Indian Islands, and part of the coast of 
South and North America, constitute its proper soil. From Brazil 
to Charleston, in one direction, and from Barbadoes to Tampico in 
another, the causes of the fever are in constant though unequal 
force, in regard to different seasons and localities. It prevails often, 
though not very generally, in some places more north than Charles- 
ton ; visits, occasionally, the Atlantic cities of our Middle States, 
and has ascended as far as Boston, while in the Mississippi Yalley 
it has prevailed as high as Memphis, perhaps Gallipolis, or even 
higher. In an eastern direction, but within the same latitudes, it 
has extended to Cadiz, Xeres, Carthagenia, Malaga, Alicant, Seville, 
Barcelona, and other cities of the coast and the interior of Spain. 
It has prevailed several times at Gibraltar, once at Eocheforcl, once 
at Lisbon, and once at Leghorn. Hence, we find it embracing a 
considerable portion of the earth's surface. In its fullest latitudinal 
extension, it reaches to between the twenty-second and twenty-third 
degrees south of the equator, and, on the other side, to the 
forty-second degree on the Atlantic coast, to the thirty-fifth degree 
on our western waters, and to the 8.56° on the Pacific. Considered 
only in reference to its legitimate longitudinal boundaries, it 
stretches from about the sixtieth to the ninety-seventh degree of 
longitude east of Greenwich. Its true area includes the Caribbean 
and other islands called the West Indies, and Bahamas, the con- 
tiguous coast of Colombia and Guatimala and the extensive shores 
of the Mexican Gulf, sweeping from Cape Catoche on the west, to 
Cape Sable on the east, and running thence along the coast of 
America to Wilmington, (N. C.,) Norfolk, Baltimore, Philadelphia, 
New York, Boston, and intermediate towns : in some of which 
places it is an occasional, not annual, or even frequent visitor. 

" Until recently, the river Amazon, which divides Brazil from 
Guiana, formed the boundary of the disease south of the equatorial 
line ; for, although it is said to have prevailed at Olinda from 1687 
to 1694, and to have shown itself as far as Montevideo in the 
beginning of the preseut century, the latter circumstance is open 
to some doubt, while in Brazil, from the close of the seventeenth 
century to the middle of the present, the disease was not observed. 
Since 1850, it has invaded Eio Janeiro, Bahia, Pernambuco, and 
other places of that country. It is, in a great measure, a stranger to 
the Pacific, having prevailed but once at Panama, twice at Guay- 
aquil, and once at Callao. It does not appear in the East Indies. 
It has never prevailed in China, Cochin China, Singapore, Siam, 
Ceylon ; it has prevailed occasionally on the African coast, Senegal, 
and the Gold coast, and has but three times, in the space of eighty- 
six years, showed itself in Cayenne. 

" Within those limits, it has, in some one or more places origi- 
nated, and prevailed to a greater or less extent — occasionally or 



574 YELLOW PEVEE. 

frequently — either as an endemic, or as a mild or wide-spreading 
epidemic. Beyond these it never shows itself; and though — 
whether north or south, east or west — it does not reach the point 
at which common malarial fevers stop, it approximates to these 
diseases ; so far, especially, as its northern or western extension is 
concerned, it being circumscribed within certain bounds ; for they, 
too, have their limits. The effect in both instances is due to modifi- 
cations in the same morbific agencies.* 

Acclimatisation is preventive of an attack of yellow fever. Thus, 
in places where the yellow fever is endemic — where the climate is 
continuously warm, -and the causes of the disease are more or less 
permanent, or frequently evolved — individuals accustomed by long 
and continued residence to the influence of the climate, and the agency 
of those causes, lose their susceptibility to an attack. But after a 
prolonged residence in cold and more salubrious localities, the indi- 
viduals thus protected lose, to a certain extent, their acclimatisation, 
and on their return to their former places of residence become once 
more liable to suffer from the disease. The children, too, of natives 
of, or those acclimatised to tropical regions, do not enjoy the same 
advantages in regard to protection, as their parents, but acquire them 
rapidly as they advance in age. The residents of some portions of 
tropical regions suffer to a certain extent from the disease, on remov- 
ing to another portion less salubrious. The protection of acclimati- 
sation is also, to some extent lost, by a long exemption of the locality 
from local sources of infection, or by the prevalence, during several 
successive summers, of a cooler and purer atmosphere than before. 

The most susceptible subjects of yellow fever are those who have 
recently arrived in infected localities, particularly the inhabitants 
of northern climates — the predisposition to an attack increasing with 
the decree of the northern latitude from which the stranger has 
arrived, and the shortness of the interval that has passed since he left 
the northern for the equatorial region. Even the inhabitants of situa- 
tions in the neighborhood of infected localities, but more elevated 
and salubrious, or of rural districts generally, though less prone to 
the disease than strangers from cold climates, are, nevertheless, liable 
to suffer when they venture in an infected place. 

As a general rule, an attack of the yellow fever exhausts the sus- 
ceptibility of the system to further attacks, or renders it less liable to 
be severely affected by the poison of the disease. Second attacks of 
yellow fever, in individuals who have passed through the disease, 
are somewhat rare ; the immunity thus obtained is greater than that 
derived from simple acclimatisation. Second attacks constitute, there- 
fore, exceptions to a rule, and are perhaps but little more frequently 
met with than second attacks of other diseases through which the 
system usually passes but once. 

Individuals of the sanguine temperament — the robust, strong, and 
plethoric are those most prone to the disease — especially when their 
mode of living is calculated to keep up that temperament, or to bring 

* Op Citat., Vol. I., p. 115, et seq. 



PKEDISPOSITION. 575 

out its elements in bolder relief. In times of unusually violent epi- 
demics, u x.en the fever spares none, individuals of all temperaments 
become alike its victims. 

As a general rule, females are less obnoxious to the impression of 
the poison productive of yellow fever than individuals of the other 
sex, and when attacked have the disease in a milder form. 

The disease, usually, effects in preference individuals of adult age — 
sparing, to a greater or less extent, young children as well as persons 
advanced in life. 

" In all places, whether within the tropics or in temperate climates, 
in which the yellow fever has manifested itself — sporadically or epi- 
demically — the negro race has manifested a greater or less suscepti- 
bility to the influence of those causes that give rise to the disease ; 
every where, however, that susceptibility is far inferior to that exhi- 
bited by the white race — the disease in the former spreading less 
extensively, and assuming usually a milder and more tractable cha- 
racter. In warm regions, the almost general exemption of the blacks 
is due, in some measure, to their being acclimatised to the country — 
a circumstance they share with Creoles, and those who are inured to 
the climate ; their more frequent liability to the disease in colder 
than in warmer regions, is due to the same cause which renders the 
white inhabitants, whether natives or long residents, more prone to 
the disease than Creoles — the want of acclimatisation. By losing, 
through means of expatriation, the power of resistance imparted by 
acclimatisation, they are placed much on the same footing as negroes 
of temperate climates, being no longer as surely exempt as they were 
before from the disease when again they are exposed to its influence." "* 

Fear, in common with all the depressing passions, are powerful 
predisposing causes of yellow fever. 

"Excessive joy, fits of anger, by stimulating the action of the 
heart and arteries, as well as the nervous system generally ; strong 
emotions of any kind ; despondency from pecuniary or other losses ; 
disappointment from even trivial causes ; intense mental application 
are no less to be deprecated, though producing their effects in a dif- 
ferent way ; while the feeling of hope, courage, cheerfulness, as well 
as equanimity of temper, have the contrary tendency, of shielding 
the system from the morbid influence of the efficient cause of the 
disease, both by promoting the healthful play of the functions, and 
placing the happy possessor of them beyond the reach of the depressing- 
passions. They prove powerful adjuvants of treatment."f 

Whilst sleep, especially in infected and exposed localities, must be 
viewed as a predisposing or exciting agent of the disease, the depri- 
vation of it — watchfulness from any cause — gives rise to the same 
effect. 

" Intemperance in respect both to food and drink ; the use, espe- 
cially when carried to excess, of aliments of an exciting and nutritious, 
as well as those of a crude and indigestible character ; unripe or acid 

* La "Roche, on Yellow Fever. Vol. 2, p. 04. 
t Ibid. Or- citat. If., 74. 



576 YELLOW FEVER. 

fruit, perhaps still more particularly the use of ardent spirits, and, 
indeed, of stimulating liquors of any kind, have almost invariably 
exhibited a tendency to excite the development of the yellow fever. 
The danger arising from such indulgences has been fully recognised 
from the earliest period, and is recorded by almost every writer, 
ancient and modern, who has treated of the cause of the disease."* 

It is proper, however, to remark, that a sudden change from a 
generous to an abstemious diet, will be apt to bring on an attack of 
the disease in individuals who might otherwise, in all probability, 
have escaped. A too rigid and abstemious diet is equally injurious. 

Immoderate evacuations ; venereal excesses ; fatigue of body from 
whatever cause induced, as well as all other things calculated to 
debilitate the system, may be ranked among the predisposing and 
exciting causes of yellow fever. 

Butchers, Curriers, Tanners, Soap-boilers, Tallow-chandlers, Sca- 
vengers, and in general, all those who habitually breathe an unwhole- 
some atmosphere are far less liable to the disease than others differ- 
ently circumstanced. While, on the other hand, Cooks, Bakers, 
Black and Whitesmiths, Hatters, Tailors, and Sugar-refiners, are re- 
puted to be particularly exposed to attacks of the disease. 

Among the more frequent exciting causes of yellow fever may be 
ranked exposure to cold in any way, especially when the body is 
heated or perspiring through the effect of exercise or otherwise, as 
also exposure to the coolness and chilliness of night air, to a shower 
of rain, &c, sleeping in the open air, or exposure in any manner to 
the night air — lying upon the ground, drinking large draughts of 
cold liquors, especially water. 

The suppression of any of then atural or of smj artificial excretions, 
as also, the sudden diminution or removal of irritations to which the 
system has become in some measure accustomed, issues, blisters, 
alvine evacuations, ulcers, chronic cutaneous eruptions, etc., have 
been found to produce an injurious result, and prove the harbinger 
of an attack of the fever. 

The diagnosis of yellow fever, under ordinary circumstances and 
to one familiar with its phenomena and course as 'contrasted with 
those of other fevers endemic to the same localities and prevalent at 
a similar season of the year, is attended with little difficulty. There 
is not, however, a single symptom appertaining to the disease, when 
viewed by itself, or without regard to the degree of its frequency, 
that can, strictly speaking, be considered as really pathognomonic, 
each of its more prominent symptoms, is, at times, absent in cases 
of undoubted character, and each will be found to occur in other dis- 
eases but remotely connected with it. But as Dr. La Roche, very 
properly remarks, when viewed in connection with each other — 
when found associated together, or -when the greater number of them 
are present in the same case — especially when this assemblage is found 
to hold in a large number of individuals affected, the result is different. 
Under those circumstances, the peculiar jaundice described, varying 

* La Roche, Vol. 2, p. 77. 



PEOGNOSIS — TEEATMENT. 577 

from the bright yellow to a dark mahogany or livid hue — the emis- 
sion from the stomach of the dark coffee-ground matter, so well known 
under the name of black vomit — the injected, brilliant, transparent, 
fiery, and glassy eye-— the* thin, slimy, white or moist, thick and dirty 
yellow fur, and clean, red edge and tip of the tongue — the super-orbitar 
pain — the rachialgia — the single febrile paroxysm, and its sudden 
cessation at the end of some forty to seventy -two hours, more or less 
— the absence, from that period, of all fever — the progressive increase 
in the slowness and depression of the pulse — the gradual loss of cuta- 
neous heat — all these may be viewed, in their ensemble, as typical of 
the disease, and as its characteristic and pathognomonic phenomena. 
When they all occur together, or when only one or two fail to do so, 
the physician may be assured he has to deal with the yellow fever ; 
and the certainty is enhanced when the case in which they are observed 
presents itself at a period of the year, and under circumstances favour- 
able to the development of the disease. On the other hand, when 
they are all, or for the most part, absent — the black vomit and jaun- 
dice particularly — we may, in the majority of cases, safely conclude 
that the disease is of a different kind, even when circumstances are 
favourable to the development of the yellow fever cause* 

The prognosis in yellow fever is upon the whole unfavourable — 
under ordinary circumstances, and with the exception only of some 
epidemics of unusual mildness, the disease is of the most dangerous 
character, and the chances of recovery are slender. But little aid is 
afforded in enabling us to arrive at a correct prognosis by the presence 
or absence of signs which in other diseases are of the highest value. 
Cases occur in which, when everything would seem to indicate a 
favourable result, the patient has been carried off with great rapidity, 
while on the other hand, cases of recovery happen in which, from the 
nature of the symptoms, a fatal termination might naturally have 
been anticipated. Dr. La Koche has presented in detail, and at great 
length, the various phenomena, the absence or occurrence of which in 
a case of yellow fever may be considered as favourable or unfavour- 
able indications, and to the work of that gentleman we must refer for 
an account of all that the most accurate and repeated observations 
have taught us in reference to the prognosis of the disease. In the 
meantime we borrow from him the following general remarks. 

1. As the yellow fever is more or less modified as to the degree of 
its prevalence, the severity of its attack, and the mortality it occasions, 
by certain peculiarities connected with the condition and habits of 
the patient, his age, sex, race, constitution, idyosyncracy, &c. ; it fol- 
lows as a necessary consequence, that when it occurs under circum- 
stances the least favourable in the above respects, the prognosis will 
be equally unfavourable. 

" Hence, we need not so much fear the issue in children, females, 
negroes, or those who have already passed through the ordeal of the 
disease, in natives of the warmer latitudes, or in those whose habits are 
temperate; while youth, a plethoric state, a sanguine constitution, 

* La Roche on Yellow Fever, IT., 565. 
37 



578 YELLOW EEVEK. 

high living, and intemperance, predispose to, while a debauch, ex- 
cessive fatigue, or terror, a fit of anger, the intemperate use of venerj, 
&c, often excite a severe attack, from which the chances of recovery 
are less to be anticipated." 

" Generally speaking, the more recently a stranger has arrived the 
more severe the attack. The same may be said of the remote cause 
itself, which, in some seasons, is of such a degree of malignancy as to 
produce a disease, which, though apparently differing little from that 
of other periods, has a greater tendency to end fatally, and must, 
therefore, call for a very different prognosis. Again, the latter must 
be more guarded during the continuance of the same epidemic in 
different parts of an infected city — the symptoms appearing the same 
— inasmuch as the malignancy and fatal tendency of the fever differ 
in them. The same remark is applicable to the several periods of 
the same epidemic. In general the prognosis should be more guarded 
at the outset, as the disease is more apt then to terminate fatally. 

" 2. As a general rule, it may be said, that in yellow fever it is not 
so much the presence of good signs which we are to look for in order 
to form a favourable prognosis, as the absence of bad signs. For, 
what would be regarded as good signs in most other diseases, are of 
little or no avail in this, and many patients recover without having 
presented what may, strictly speaking, be called by that name ; often 
after exhibiting some one or more of those which experience, in 
many fatal cases, teaches us to look upon with suspicion ; whereas, 
the appearance of any one of the decidedly bad signs, and still more 
a combination of them, must be viewed with fear, leading, as they 
very generally do, to a fatal termination. 

" 3. It is not less to be noted, that much more is to be expected 
from a gradual amendment of the febrile and other symptoms than 
from a sudden disappearance of even the most unfavourable among 
these. From the latter change, indeed, the most disastrous results 
may in general be expected — followed, as it generally is, by delirium, 
coma, and other bad symptoms. The danger of the disease, great as 
it is, when the latter is uncomplicated with any other complaint, be- 
comes much more so, and calls for a more unfavourable prognosis, 
when to the phenomena which reveal its existence, are superadded 
those indicating the coexistence of other disorders. 

" 4. "With the exception of the mildest or ephemeral forms of the 
disease, the danger to be apprehended is, generally speaking, propor- 
tionate to the shortness and rapidity of the case. When the disease 
extends to the seventh, ninth, or eleventh day, recovery may reason- 
ably be expected. The same favourable view may be taken from the 
prolonged duration of the stage of reaction — the danger in the subse- 
quent stage being 'proportioned to the shortness of the first, and the 
early supervention of the state of metaptosis. 

"5. In cases marked by remissions, the disease, as we have seen, 
is of a milder character, and admits, therefore, of a much more favour- 
able prognosis, however severe the febrile reaction may be during the 
exacerbation. 

"6. Rigors, at the commencement of the attack, denote considerable 



TREATMENT. 579 

danger, and are usually viewed as signs of fearful omen, the danger 
being proportionate to their duration. The same may be said of 
chills, when violent, long continued, and repeated." 

" 7. Considered in a general way, the yellow discoloration of the 
skin, which has given a name to the disease, is doubtless a sign of 
importance in a prognostic point of view ; for, though not invariably 
observed in all fatal cases, it is much more frequently seen in these 
than in cases of recovery. Hence, generally speaking, the appearance 
of this symptom must be regarded as entitled to considerable atten- 
tion, and held with suspicion. 

" The appearance of jaundice at an early period of the disease may 
be viewed as a symptom of serious import, and as indicating a disease 
of dangerous, and even fatal character — the danger increasing in 
proportion to the deepness of the discoloration. When, on the con- 
trary, it appears at a late period — after the sixth or seventh day — it 
loses the dangerous tendency in question, and, as we have seen, may 
even be said to assume the character of a critical sign. As regards 
the peculiar hue' it presents: in many cases, and during certain epi- 
demics, the light yellow or lemon colour has proved more dangerous 
than the dark yellow; while in other seasons and localities, the 
reverse is said to have been the case. Jaundice is indicative of more 
danger when it assumes a greenish, violet, mahogany, or bronze hue, 
and particularly when the skin presents a mottled or party-coloured 
appearance, characterised by livid, olive, and ash-coloured patches of 
all sizes, and blending into each other. Greater apprehension is to be 
felt when the discoloration in question is rapidly and very extensively 
diffused over the body, than when it is limited in extent, and spreads 
slowly."* 

In proceeding to a consideration of the treatment of yellow fever, 
we may remark, that this must be based upon the character assumed 
by the disease in its different visitations, and even in each separate 
case that presents itself. The same therapeutical measures are not 
adapted alike to the inflammatory and to the congestive forms of the 
fever. Nor will the same course of treatment tend to conduct to a 
favourable termination those cases, in which, from the very onset, the 
disease assumes an unquestionably malignant or deadly aspect, and 
those the symptoms of which are so mild, that recovery will be sponta- 
neously, or with but slight aid from medicine — while it will be as 
little adapted to the cases intermediate between these two extremes — 
where the object of the physician should be to apply in time those means 
best calculated to produce a favourable impression on the train of 
morbid actions, and thereby arrest their dangerous tendencies. 

The treatment of yellow fever must be modified according to a 
variety of circumstances. As remarked by Dr. La Eoche, "in encoun- 
tering this formidable disease, we must content ourselves with endea- 
vouring, not to neutralise the poison circulating in the system, but to 
correct the morbid effects it occasions on both solids and fluids. We 
must, while watching carefully the course of the disease, prevent 

* Op. citat. I. p. 478, et seq. 



580 YELLOW FEVEE. 

undue mischief from being done, especially to organs essential to life. 
We must keep these organs in as healthy a condition as possible- — 
restore, if possible, equilibrium in the play of the functions — reduce 
undue and dangerous excitement, general and local, and sustain the 
powers of life when these threaten to become impaired, or are already 
reduced beyond the point of safety. But we are forced to confess 
that, beyond this, art is of little avail. The idea of curing the disease, 
or greatly abridging its course, is entitled to little confidence. To 
nature must be left the chief management of the case ; time must be 
allowed for the elimination of the poison ; and the physician must be 
impressed with the conviction that, in cases where no marked organic 
mischief has been done, or is likely to occur, he must keep his hands 
off as much as possible, and restrict his agency to the employment 
only of such means as are strictly necessary to fulfil particular indi- 
cations. He must not attempt to do what is more safely done by the 
recuperative powers of the system, and rest assured that in these, and 
indeed in all instances, more danger is to be apprehended from 
too great than too little interference on the part of the medical 
attendant." 

"When called to a case of yellow fever, a primary object of solicitude 
on the part of the physician, should be, to guard as much as possible 
against all disturbing influences. He must see that the patient 
is confined effectually to his bed, and prevented from rising. He must 
give proper directions for the free ventilation of the apartment, and 
the preservation of cleanliness ; while, whatever be the form the dis- 
ease assumes, he should proceed to the medical treatment of the case 
with the least delay possible. The great rapidity with which the 
dangerous symptoms make their appearance, the little time afforded 
for preventing their .onset, and the great importance of effecting 
that object — besides the difficulty of their removal when they do 
appear — render such promptness imperative. At the same time, a 
knowledge of the insidious and treacherous nature of the disease, the 
great difficulty of predicting whether symptoms indicative generally of 
a mild attack are not soon to be succeeded by those of an opposite 
kind, and whether changes calculated to make us hope for a favour- 
able issue are not to be followed — perhaps in a few hours — by others 
portending approaching death, should make him constantly attentive 
to the nature and succession of every phenomenon. 

Attention being paid to these details, the medical treatment will 
necessarily vary according to the particular form which the disease 
assumes. In the several varieties of the inflammatory form, recourse 
must be had to antiphlogistics, sedatives, and evacuants, graduating 
the energy of these to the degree of the violence of the reaction, the 
force of the circulation, the heat of the skin, and the extent of the 
local inflamations or congestions. Of the indispensable necessity of 
antiphlogistic and evacuant treatment, which in this, as in other 
fevers of kindred nature, consists in sanguine evacuations, sedatives 
— internal and external — and purgatives, there can be no doubt. 
It is based on the evident character of the complaint, and the sue- 



TREATMENT. 581 

cess which has attended its application ; and comes to us under the 
sanction of innumerable and high authorities.* 

The foregoing remarks apply exclusively to the first stage of the 
inflammatory form of the disease ; while to be productive of benefit 
they must be resorted to without loss of time — their success being 
proportionate to the earliness of their application. They are not, it 
is also to be recollected, as a general rule, to be used with the same 
freedom as in ordinary inflammations. Except when there is inor- 
dinately high reaction — or when important organs are seriously in- 
flamed or congested, and the patient is vigorous, plethoric, and 
young, and the recuperative powers of the system energetic, it would 
be safer to avoid the use of agents calculated to debilitate suddenly 
and considerably, and to trust to milder means. While endeavour- 
ing to relieve inflammation or congestion, we should never lose sight of 
the imperative necessity of husbanding the strength of the patient, 
and of avoiding every thing calculated to depress the powers of life 
and foster the tendency to collapse. 

While general excitement, local inflamations and congestions, 
if they exist, are reduced by suitable depletion and sedatives, and 
the bowels, when costive, opened by mercurial and other purgatives, 
attention must be paid to tranquilize the stomach — and the physi- 
cian must watch the efforts of nature, and promote any critical move- 
ment she may indicate. 

Various means have been proposed and recommended to calm the 
stomach. Leeches or cups to the epigastrium in cases where they 
are admissible, have, occasionally, been found beneficial. Lime 
water by itself or combined with an equal quantity, or two-thirds of 
new milk, in doses of a wine glassful has been highly recommended ; 
other means have been also used with more or less success. 

Among these may be enumerated the carbonates of soda and 
potass, the saline mixture, the effervescent draught, yeast, calcined 
magnesia, porter, chalk mixture, liquor potassse in barley water, 
carbonate of ammonia and hydriodate of potassium and spruce beer 
and essences. Of all remedies of the alkaline class, the chlorate of 
potass is entitled to most notice in this place, from the praise it has 
recently received from the high authority of Professor Frost, of 
Charleston. 

The nitrate of silver — small doses of creasote diffused in water — 
chloroform, in doses to the extent of even half a drachm, have 
likewise been recommended — they would all appear to us to be 
of doubtful propriety in the first stage at least of inflammatory 
cases. 

After the more decided inflammatory symptoms have been sub- 
dued, turpentine, combined with a portion of mucilage, in doses of 
ten drops every two hours, will often be found very speedily to cheek 
vomiting — under the same circumstances also, a blister or sinapism 
over the epigastrium will be found of service. The ascetate of lead, 
in doses of from grs. 2-J or 3, every three or four hours, either in 

* La Roche, II., 635. 



582 YELLOW FEVEE. 

pills or simple solution, has been highly recommended, and will 
sometimes succeed in restraining the frequent retching and violent 
vomiting so characteristic of the disease. When we have succeeded 
in checking the violence of the fever and in relieving whatever 
local irritation or congestion that may be present, and an intermis- 
sion has been obtained, " or," to use the language of Dr. La Eoche, 
" when the latter or metaptosis has occurred at the regular time by 
the spontaneous subsidence of the febrile excitement, little remains 
to be done beyond keeping up the strength of the patient by mild 
tonics and light nourishment, and preventing, if possible, the onset 
of further and malignant symptoms, by the use of antiperiodic, tonic, 
and astringent remedies. But when the remission is incomplete, or 
is succeeded by a train of symptoms indicating a continuance and 
exasperation of the disease, another and different course must be 
pursued. The irritability of the stomach and the vomiting, as also the 
inflammation of that organ, if it occur, must be combated by seda- 
tives and antacids internally, emollients and revulsives externally ; 
the cerebral organs, if implicated, must be attended to, and their 
irritation or congestion treated by ordinary means; the failing 
powers of the system must be sustained by nourishment, tonics, and 
stimuli, either by the stomach, if it will bear them, or, in the con- 
trary event, by the rectum ; while the hemorrhagic tendency must 
be arrested by astringents or other suitable remedies. 

In the congestive form of the disease, when the reaction is defi- 
cient or altogether wanting, recourse must be had to means calcu- 
lated to arouse and sustain the dormant energies of the system, and, 
at the same time, to relieve the sufferings of the overloaded organs. 
External stimulation, by means of rubefacients, hot baths, sinapisms, 
vesicatories, &c. ; the internal use of stimuli, tonics, &c, by the 
stomach or bowels, and, in the milder cases, stimulating and mer- 
curial cathartics, must be resorted to ; and, whenever it can be 
done with safety, the congested vessels of important organs, and the 
inflammation of particular parts, which sometimes is combined with 
the congestion of others, must be relieved by general and topical 
bleeding. 

Local depletion, by cups or leeches, may be resorted to in many 
cases of yellow fever, where general depletion is not considered 
advisable ; or for the relief of particular organs. The cups or leeches 
should be applied as near as possible to the part affected — on the epi- 
gastrium, when the stomach is to be relieved; on the temples, along 
the course of the jugular veins, inside the nostrils, or at the back of 
the neck, when the condition of the encephalon calls for assistance. 
As a general rule, local depletion should be resorted to at as early a 
period of the disease as possible. When practiced late, it is of no 
utility, and may even act disadvantageously, by increasing the pros- 
tration of the powers of life. 

Sudoriflcs are strongly recommended by many in the treatment 
of yellow fever in its earliest stage. The warm and vapor baths, or 
pediluvia of warm water, or warm water with mustard, aided by 



TREATMENT. 583 

warm lemonade, or a warm infusion of some agreeable vegetable 
substance, have unquestionably been found, in many cases, when 
properly timed, to produce a general diaphoresis, from which very 
decided relief has been obtained. It is only at the very onset of the 
milder cases, however, that much benefit is to be expected from these 
sudorrfi.cs. In the more decided inflammatory forms, they cannot fail 
to prove prejudicial. From the irritable state of the stomach, there 
is little to be expected from the usual diaphoretics internally ad- 
ministered. 

The warm bath is particularly appropriate when, in the early 
stage, the reaction is imperfect, partial, or deficient— when, in a word, 
the disease assumes one of the grades of the congestive form. In 
such cases, a general bath of high temperature — not less than 100° 
— will tend to promote a return of heat to the surface, and diffuse it 
if unequally distributed, and at the same time revive the activity of 
the circulation. In general, the water may be used alone ; but in 
the case of extreme collapse, its beneficial effects will be greatly 
enhanced by the addition of salt, spirits, or mustard. 

There are a number of means which may be resorted to, in order 
to meet particular indications — to relieve pain and local inflammation. 
Pediluvia, warm or tepid, fomentations and cataplasms are generally 
used, and found useful. Warm frictions, either dry or with soap, with 
hot oil, whiskey, or stimulating lotions, or, again, with lemon juice, 
will also find a useful application. The latter means — frictions with 
lemon juice — constitute a main instrument of what is called the Cre- 
ole treatment, or that of the colored women of the "West Indies, and 
is favorably spoken of by the medical writers of experience in tro- 
pical climates and this country.* 

In the early period of the first stage of the fever, when the skin 
is hot and dry, cold water, applied over a considerable extent of the 
surface, either by sponging or affusion, has been found, at times, to 
exercise a beneficial influence, and by many physicians, is considered 
an important agent in the treatment of the disease. Such has been 
the case in tropical climates, and the results there obtained will be 
found fully corroborated by those recorded in temperate latitudes. 

The same rule must be observed in the application of cold water 
in cases of yellow fever, as in other febrile diseases — namely, it 
should be resorted to, only when the skin is decidedly hot and dry, 
and the reaction well established. Under such a condition of things 
the application of the cold water is usually followed by a reduction of 
heat and of vascular action, as well as, also, in numerous cases, by a 
tendency to perspiration, a sensation of comfort, and an abatement of 
many unpleasant symptoms. The same effects, but in a less degree, 
will result from partial applications of cold water or cold pediluvia. 
When applied, on the contrary, under other circumstances, very 
opposite results will very generally follow. 

"If," as Dr. La Eoche well remarks, "the skin be cool and the 
pulse depressed, the sedative effect of cold water will hav< a ten- 

* La Roche, Op. citat. 



584 YELLOW FEVEE. 

dency to aggravate the symptoms. Eeaction, in such, cases, seldom 
occurs ; the disease becomes more concentrated within the internal 
and important organs, and the prostration of the vital powers 
increases rapidly. When the skin, instead of being dry, is warm, 
moist, and relaxed — which, as seen, occurs sometimes in all epidem- 
ics, and very generally in others — the application of cold to the sur- 
face has a tendency to check the salutary condition, and will almost 
always sorely aggravate instead of benefiting the disease. Nor are cold 
ablutions to be less avoided when the patient complains of chilliness 
or dyspnoea ; or when he labors under diarrhoea, or deep congestion, 
or well-marked inflammation of internal organs; or, again, when he 
is of weak constitution or of advanced age." 

" In cases attended with a moderate degree of temperature of the 
surface ; or when, after depletion, or without, the skin exhibits a ten- 
dency to perspiration ; when, again, the patient suffers from restless- 
ness or other nervous symptoms, or when the shock from cold water 
is unpleasant, the tepid bath, or ablution with water of slightly ele- 
vated temparature, or a sheet dipped in tepid water, is found highly 
advantageous " 

" In cases in which it is inconvenient or improper, for particular 
reasons, to have recourse to the hot or tepid bath—general or partial 
— the effect will often be obtained by means of the artificial vapor- 
bath, obtained by pouring water, either alone or mixed with vinegar, 
on hot bricks and introduced under the bed clothes.". 

It is scarcely necessary to point out the importance of placing the 
patient in apartments, large, clean, dry, arid, well ventilated, and so 
situated as to secure for him the advantages of pure, cool, fresh air. 
Under all the circumstances of the disease, let whatever be its form, 
this is an all-important measure. 

The drinks of the patient should be cool and refreshing — in the 
first stage of the inflammatory form of yellow fever, cold water 
is perhaps the best, taking care, however, that it be taken in mode- 
rate draughts, at short intervals, to avoid over distension or prostra- 
tion of the stomach. Where the stomach is irritable, and bears 
with difficulty the ingestion of water or other cool liquids, small 
portions of ice, held in the mouth and slowly swallowed, will often 
prove highly refreshing. 

A variety of drinks have been suggested, and in many cases may 
be resorted to with advantage, as weak lemonade or orangeade, 
tamarind, currant jelly, and raw-apple water ; thin flaxseed, or gum 
water, plain or sweetened ; iced carbonic acid water. " Under the 
use of cold and iced drinks, the irritation of the gastric mucous 
membrane," remarks Dr. La Eoche, " often subsides ; the sense of 
heat and ardour at the epigastrium ; the nausea and vomiting ; gas- 
tric haemorrhage, as well as the general excitement of the heart and 
arterial system, diminish ; while the temperature of the skin is apt 
to lessen, and a disposition to perspiration not unfrequently mani- 
fests itself. 

"But, in all cases — even in those characterised by considerable 
thirst — care must be taken not to overload the stomach, as nausea 



TREATMENT. 585 

and vomiting will almost inevitably be the result. The preferable 
plan is to direct the patient to drink often and to take but a small 
quantity at a time. Even in cases unattended with much thirst or 
irritability of the stomach, it is proper to enjoin the same rule of 
frequent and moderate drinking, for the double purpose of soothing 
the irritation of that organ, and guarding against awakening a dis- 
position to nausea and vomiting, which, as we have seen, are almost 
constant attendants on the disease, and require but a trifling cause 
to bring them on. 

" In cases characterised by symptoms different from those enume- 
rated, the drinks should be of a higher temperature ; and where 
there exists a tendency to perspiration, they should, the condition 
of the stomach allowing, be taken warm and slightly aromatized. 

" In an advanced stage of the disease — when the powers of life 
are fading, the drinks should be of a stimulating and nourishing 
kind. Porter and water, weak punch; weak wine-whey, claret, 
champagne, or hock wine, brandy and water, &c." 

TVhen the gastric irritability is so great as to forbid the admission 
of any thing into it, much benefit is often derived from the use of 
small and strongly purgative enemata. They act on the principle 
of revulsion — excite the peristaltic action of the tube downwards, 
and thus tend to quiet the stomach. In the advanced stage of the 
disease, especially when the stomach rejects every thing, stimulating 
and tonic substances, introduced by means of injections, sometimes 
prove serviceable. 

Blistering is not admissible in the early stage of the inflammatory 
form of yellow fever. At the commencement of the second stage — - 
when symptoms of an unfavourable character are present, blisters 
to the ankles and other parts will often produce a favourable revulsive 
action, or prevent the depression of the vital powers. At a later 
period of the disease, when symptoms of prostration present them- 
selves, blisters, in conjunction with other stimulants and excitants, 
will not unfrequently contribute in arousing the sinking energies of 
the system. 

In the early period of the congestive form of yellow fever, blisters 
are adapted to aid in the restoration of action to the surface of the 
body, and in the excitation of the general circulation and nervous 
system. 

To relieve gastric distress, pain, nausea, and vomiting, in cases 
where the febrile excitement does not run high, or in the second 
stage of the disease, blisters to the epigastrium or spine will often 
prove serviceable. 

To relieve the headache, delirium, and stupor, attendant on the 
various stages of the disease, blisters to the nape of the neck, the 
occiput, or the upper extremities, will, also, not unfrequently. he 
decidedly beneficial. So, likewise, pain in the region of the thorax, 
whether resulting from disease of the lungs or external muscles, as 
well as the tormenting rachialgia, is sometimes relieved by blisters 
to the affected parts. 

In order to obtain the effect desired from the application of 



585 YELLLOW FEYEE. 

blister; it is not always necessary to produce vesication. By 
removing them so soon as they have produced a rubefacient effect, 
a revulsive action is obtained without risk of gangrene, soreness, or . 
haemorrhage, while the effect may be renewed when it subsides too 
soon. 

Sinapisms may, in many cases, be usefully substituted for blisters, 
and should always be preferred when the urgency of the symptoms 
calls for a prompt and energetic treatment. They are particularly 
useful to . tranquilise the stomach, and remove local pain ; and, in 
congestive, as well as in the advanced stages of ordinary cases, to 
invite excitement to the surface, and arouse the failing power of the 
nervous and arterial systems. By some they are used early to coun- 



teract congestion. 



While all internal stimulants are strongly contra-indicated in the 
first stage of the inflammatory form^of yellow fever, in cases in 
which from the onset the reaction is feeble and deficient — in 
some of the modifications of the congestive variety — they are 
sometimes required to arouse the energies of the vascular and 
nervous systems — even when bleeding and other means of deple- 
tion are employed to empty the congested organs. In not a few 
cases, however, of even the congestive form of yellow fever, the 
early use of stimulants is unnecessary and improper. It is chiefly 
in the advanced or sinking stage of the disease that they are admis- 
sible ; and they are here often required in very large doses. They are 
sometimes instrumental in sustaining the powers of life or mitigating 
particular symptoms, and thereby enabling the patient to outlive the 
disease. 

Nearly all the articles included in the class of stimulants have 
been recommended, capsicum, serpentaria, wine, brandy, ammonia, 
camphor, chloride of sodium, sulphuric ether, spirits of turpentine, 
etc. No one of these can be considered as specifically adapted to 
the disease ; all have no doubt been found useful, and it is equally 
certain that all have equally failed. 

Opium, which is admissible, at an early period of the disease, only 
in the decidedly congestive form, when stimulating means are 
required to rouse the prostrated powers of life, has been recom- 
mended in the latter stage of ordinary cases to support the system — 
and, in combination with the other stimulants may, sometimes, be 
found useful. 

At this particular stage the cinchona bark, quinia, and the tinc- 
ture of the hydrochlorate of iron, have been recommended as tonics. 

The Peruvian bark, which has been suggested by some as an 
appropriate remedy even at the very onset of the fever, and by 
others at the close of the first stage or during the remission, is 
now, we believe, very generally considered as useless, or even mis- 
chievous, except during the last or sinking stage, when, probably, it 
may sometimes do good as well by its tonic as its astringent proper- 
ties. Of the sulphate of quinia, which has supplanted the bark as a 
therapeutic agent, the same remarks may be made. 

Of late years the quinia has been recommended at the very onset 



TREATMENT. 587 

of tlie attack, in large doses, "with the view of at once cutting short 
the disease. In reference to the success of this abortive treatment of 
yellow- fever, as it has been termed, we have been favoured with much 
discordant testimony, but none of sufficient weight and clearness to 
recommend it strongly to our notice. 

The muriated tincture of iron comes to us with such strong testi- 
mony in its favour as a remedy adapted to even the earlier stages of 
yellow fever, that it demands a further trial. 

We have said nothing as yet of the mercurial treatment of yellow 
fever, so highly lauded for its superior efficacy by several physicians 
of high repute. It does not appear to us that any evidence has been 
adduced to prove that this plan of treatment has been more successful 
than others ; while from the known effects of the mercury upon' the 
blood, we should apprehend an increase of the very morbid condition 
of that fluid which, from an early period of the attack, constitutes so 
prominent a feature of yellow fever. From these considerations, and 
the uncertainty of our being able to place the system under its spe- 
cific effects — the probable failure, even when obtained, of their pro- 
ducing the desired result, and the time lost in waiting for those 
effects to develope themselves, we should be inclined to reject mercury 
from the list of the therapeutic agents adapted to the disease. 

In the management of a case of yellow fever, more perhaps than 
in one of any other disease, is it important to remove from the 
patient all impressions of a moral kind — to keep up his spirits and 
sustain his courage. His alarm and anxiety for the result of his case 
must by every means, if possible, be quelled, and the stimulus of hope 
constantly kept alive ; unless this be done — remedies are of little avail. 

In the early stage of the inflammatory form of the disease, total 
abstinence from food should be enjoined, or only thin gum, rice, barley, 
or apple water allowed; or in the milder cases, arrow-root, sago, 
Indian, or oat-meal gruel, or the like, may be allowed in small 
quantities, and at reasonable intervals. 

When the activity of the pulse has been reduced, and the skin 
softens and loses its excess of temperature ; when the gastric irritation 
lessens also, and especially when the stage of metaptosis sets in with 
fair prospects of increasing amendment, the diet should be made 
more nourishing. 

Animal food, whether in the form of soup, carefully freed from fat, 
or in substance, may be given, but with great circumspection; it 
may even be better to restrict the patient to farinaceous and vege- 
table articles. Thin rice and bread cream, arrow-root, sago, Indian 
mush, oat-meal gruel, slightly sweetened and aromatised, thin panada, 
weak coffee, tea, or chocolate, milk and barley-water, answer well, 
when given in small quantities at a time, and at short intervals. 
They are better suited than animal food to the existing condition oC 
the digestive powers, which are often considerably impaired. 

Wine, and other spirituous liquors, except when the debility is 
unduly prominent, and all signs of inflammatory irritation have sub- 
sided, must be avoided as unnecessary and often hurtful. Consider- 
able attention is also required as to the quantity in which food is 



588 YELLOW FEVEE. 

allowed — much mischief is often done by the patient indulging largely 
in even the most bland and proper articles. As a general rule, it is 
safer to give but a small portion of nourishment at a time, and gradually 
to increase the quantity. 

As febrile irritation and gastric irritability further subside, and the 
favourable crisis approaches, the food must be given at shorter inter- 
vals, and rendered more nourishing. It may now consist of the same 
articles prepared in a more generous manner, or of milk, stewed fruit, 
chicken or veal broth. When the debility is considerable, beef-tea, 
animal jelley, &c, may be allowed. This choice of aliments, graduated 
in the way mentioned, to the condition of the digestive powers and 
of the system at large, must be persevered in to the period of con- 
valescence. It is equally well suited when the disease, instead 
of progressively subsiding without the occurrence of bad symp- 
toms, passes to the third stage, or that of depression. When, how- 
ever, the disease assumes a malignant character, and symptoms of 
positive prostration call for tonics and stimulants, nourishing food, in 
the form of strong broths, essence of beef, animal jellies, administered 
often and in small bulk, may be tried as long as the stomach remains 
quiet, and it has sometimes proved advantageous. 

In congestive cases little or nothing can be done in the way of 
diet so long as reaction has not taken place. When reaction has been 
brought about, the diet must be regulated in the manner already ad- 
verted to. 

During convalescency, while the use of the remedies employed in 
the preceding stage, is to be gradually diminished, the patient must 
be allowed more and better food, but the transition to the diet of 
health must be gradual, and care must be taken to select none but light 
and nutritious articles, and to avoid indulging in these frequently, 
and especially overloading the stomach. For some days, unless the 
debility be great, and all signs of gastric irritation completely sub- 
dued, the patient had better abstain from animal food, and limit him 
self to the use of eggs, bread, rice, bread and milk, panada, and 
oysters. As strength returns, and the functions of the stomach, 
acquire energy, he may be allowed chicken, veal, mutton, or beef 
broths, prepared with a large proportion of rice, barley, and other 
vegetables. Poultry, game, and fish may follow ; and finally, the 
more substantial meats may be allowed. 

But necessary and indispensable as this gradual return to the diet 
of health undoubtedly is, the physician does not always find it pos- 
sible to enforce compliance; for there is often such a sudden revival of 
the appetite for animal food at the commencement of convalescence 
that it is difficult to restrain the patient within proper bounds. 

Cases not unfrequently occur, in which, from feebleness and languor 
of the stomach, or a state of general debility, mild, and even strong 
tonics and stimulants are called for. Under these circumstances, the 
infusion of bitter plants, of Peruvian bark, of serpentaria, or the sul- 
phate of quinia, will prove serviceable ; while malt liquors, wines — 
claret, sherry, madeira, hock — and even brandy and water, find a 
successful application. 






TREATMENT. 589 

Haemorrhages occasionally occur during convalescence, which, as 
they indicate great debility of the system, and an atonic condition of 
the vessels, and tend to increase, by the loss of blood they occasion, 
the very cause on which they depend, must be checked with the least 
possible delay. In these cases, acids internally, and nitrate of silver, 
creasote, or the tincture of iron externally, cool air, as well as reme- 
dies calculated to impart tone to the system at large, are employed 
with advantage. 

Quiet and cheerfulness of mind must be secured, and sleep must 
be encouraged. They are essential to a rapid and complete reco- 
very. So long as debility is prominent, bodily exertions must be 
avoided; but, as soon as the strength admits of it, exercise, alter- 
nating with rest, and graduated to the condition of the patient — 
short, and frequently repeated — must be enjoined. The venereal 
act — to which, convalescents are prone — should be carefully avoided, 
as always highly detrimental, and often, when indulged in to any 
excess, of fatal tendency. 

Great stress must, at the same time, be laid on cleanliness and free 
ventilation, but more particularly on change of locality, and removal 
from the infected to a pure and cool atmosphere. 

When circumstances will permit, and convalescence is long and 
tedious, a sea voyage, and a residence in a cold climate, must be 
recommended. Editor.] 



590 EPIDEMIC CHOLERA, 



EPIDEMIC CHOLEKA. 

Epidemic Cholera. — This disease, when it runs its full course, ter- 
minates in a state which is unquestionably one of fever, and as that 
fever is often attended by a characteristic eruption, it appears to 
approach more nearly to the eruptive fevers than to any other class 
of diseases, yet to avoid the imputation of theory, we have not con- 
nected it with any. 

In the larger proportion of cases, the development of this frightful 
disease is preceded by a premonitory stage, of which the symptoms 
are those of simple diarrhoea, though generally of a more than usually 
obstinate character. In some instances, too, the patient does not feel 
generally ill, and though, from the prevalence of the disease at the 
time, he may have some misgivings as to its true nature, he is will- 
ing to flatter himself, and eagerly assures his friends, that his diar- 
rhoea is of a healthy or conservative character. In others, again, 
there is, during this premonitory stage, more or less of a feeling of 
general illness ; pains in the abdomen, and especially across the epi- 
gastrium ; coldness of the extremities, slight cramp in the calves of 
the legs, exhaustion, anxiety, and alarm. After these symptoms have 
continued, in some cases for several days, in others for only a few 
hours, the true choleraic symptoms declare themselves more or less 
quickly. 

Sometimes, on the other hand, the attack is fearfully sudden. The 
patient is seized without any previous warning, often about two o'clock 
in the morning, with a pain across the epigastrium, commonly at- 
tended with desire to go to stool ; he does so, and passes a copious, 
often a bulky and healtlry evacuation. This is very soon followed 
by another, and then another and another in rapid succession, the 
motions passing quickly into the true choleraic character, of a liquid 
resembling thin rice-water, sometimes even a limpid fluid, with just 
a few shreds of a white substance suspended in it. With this purging 
there is commonly vomiting, the matter ejected from the stomach 
being the same in appearance as that passed from the bowels. Some- 
times the purging is so incessant, that the liquid streams from the 
patient without his having the power to restrain it. There are now 
severe cramps, commencing generally in the calves of the legs, and 
extending to the abdomen and upper extremities, sometimes affecting 
even the muscles of the face, and not unfrequently, judging by the 
character of the pain, the diaphragm ; there is also a total suppression 
of the urine, and, as may be inferred from the colourless appearance 
of the stools, of the bile also. There is urgent thirst ; the patient is 
deathly cold to the touch, but complains much of heat ; the skin 
streams with a cold perspiration ; the extremities become shrunken 
and sodden, as if they had been long immersed in water ; the hands 



SYMPTOMS, 591 

and feet, and eventually the whole surface assumes a livid, leaden 
hue ; the pulse becomes almost imperceptible at the wrist, sometimes 
quite so ; the tongue is white and cold, the breath like a stream of 
cold air, and the surface of the body exhales a cadaveric odour ; there 
is incessant jactitation of the limbs, resembling that of exhaustion by 
haemorrhage. The cheeks are hollow, the countenance dark and duskv. 
and round the eyes, which are sunk in their orbits, there is a still 
darker circle. The voice is plaintive, and like a hoarse whisper, and 
startling the attendants by its unearthly sound. 

In many of the severest cases, the purging ceases after it has con- 
tinned for many hours, apparently because the system is thoroughly 
drained, and a state of most profound collapse may continue for many 
hours, when, if no reaction takes place, the patient dies. 

The mode of death is somewhat remarkable ; the organic life seems 
to be the first extinct, after that the animal powers of voluntary 
motion, and lastly the intellect, which remains undisturbed till death, 
This appears to be, in fact, a manner of dying different from those 
which we have hitherto noticed. It is not death from the heart, or 
death from the brain, but death beginning in the extreme of circula- 
tion, the heart, and lastly the brain failing in their functions from 
want of blood, the supply of which is cut off by the drain from the 
mucous surfaces and the skin ; or it may be said to be death from the 
blood, which when drawn is black and pitchy, from having been 
drained of its liquid. 

' If the patient do not die in this stage, reaction, as it is termed, 
ensues, the pulse returns at the wrist, and the skin recovers its. 
warmth; after a time, the secretions of bile and urine reappear, and 
the patient, exhausted indeed, and emaciated, but apparently free 
from disease, steadily, and sometimes with astonishing rapidity, 
regains his health. In a large number of cases, unfortunately it is 
not thus, but reaction leads to fever, and the fever is apparently of a 
specific character. After three or four days the patient begins to 
pass urine, generally of a dingy color ; there is frequent vomiting of 
a green bilious fluid, and at the same time there are signs of stupor, 
or coma. The pulse is sharp, with a light back-stroke, and very 
compressible. Many — by far the greater number of patients thus 
affected, pass into a state of most profound coma, and so die. 

In the course of the consecutive fever just noticed, an exanthema - 
tons rash frequently makes its appearance, which has been describ 
by Dr. Babington, who was the first to call attention to it: "After 
this" (the typhoid consecutive fever) "has existed several days, some 
red spots are observed about the wrists and hands, and the face 
becomes tumid, as on the approach of erysipelas. If this occur in 
the evening, on the following morning the arms, the forehead, up 
the roots of the hair, and the face generally, will be covered with 
large elevated patches, of a bright-red color, more raised than mea- 
sles, and more defined than scarlatina, much resembling lie 
especially in the circumstance of their disappearance on pressu 
and instant recurrence when that pressure is removed." 

Such are the more prominent features of this frightful malady. 



592 EPIDEMIC CHOLERA. 

which, we have been compelled to sketch thus brifry. Into the differ- 
ent opinions which have been entertained respecting its pathology, 
we cannot of course enter, but we submit that which seems to us 
most in accordance with general pathology, and the facts of the 
case. 

The morbid anatomy of cholera tells us little, as no appearances 
have been found, which in any way account for the symptoms. The 
most important are perhaps the capillary hyperemia, the venous con- 
gestion, and the oedema of the mucous membrane of the stomach 
and small intestines, more especially of the duodenum. There is, 
too, another, to which we believe an exaggerated importance has 
been attached, namely, the distension of the gall-bladder with bile. 

The state of the intestinal membrane indicates the irritation that has 
been set up there, and this, too, seems to show that' there has been 
an arrest of the capillary circulation, that arrest being followed, as 
we have elsewhere seen to be the case, by an exudation of the watery 
parts of the blood ; that this is so is further shown by the ©edema- 
tous condition of the sub-mucous areolar tissue. This seems to be 
the first link in the chain of diseased action which we are at present 
able to reach. But granting this, and that from hence the serosity 
of the blood is continually draining, the other phenomena follow as 
a matter of course; hence the thick tarry state of the blood, hence 
the suppression of urine (p. 35), hence the thirst (p. 78), hence the 
urea in the blood (p. 35), hence the suppression of bile (p. 35), hence 
the cramps (p. 393), hence the failure of the heart's action, of the cir- 
culation, and of animal heat ; hence the ursemic poisoning, and subse- 
quent death by stupor or coma. We would here remark that some 
importance has been attached to the gall-bladder being full; now it 
does by no means appear that this proceeds from any excessive secre- 
tion, it is merely, as Dr. Ghill has remarked, such a condition as is 
common when the digestive function is long interrupted, and indi- 
cates rather a passive than an active state ; but, as the same physician 
remarks, there are cases where the membrane of the ducts and gall- 
bladder is the seat of the cholera process. We believe that in many 
cases, the fulness of the gall-bladder is produced, not by pure bile, 
but by choleraic effusion from its lining membrane, colored by bile 
which had been already secreted. The seat, then, of the mischief is 
in the mucous membrane, beginning at the stomach and small intes- 
tines, and extending throughout its surface, so that the skin, which 
is one of its prolongations, is also similarly implicated, and further 
loss of fluid takes place from thence. 

We may here remark that a frequent and troublesome sequel of 
cholera is gastric irritation, some patients being subject to it for 
months and years afterwards. In the consecutive fever, too, there 
is evidence of acute irritation of the gastro -intestinal mucous mem- 
brane. May not the rash have been an analogous affection of the 
skin? 

The diagnosis of cholera, when established, is obvious. From the 
English cholera it maybe distinguished by the absence of bile in the 
ejected matters, by the voice, and by the tongue. When there is 



ITS PATHOLOGY, 593 

premonitory diarrhoea, the signs of impending cholera are duskiness 
of the extremities, cold tongue, failing pulse. 

The prognosis of true epidemic cholera is in the main unfavour- 
able; at the commencement of an epidemic of cholera, nine out of 
ten die. Upon an average, at least one half of the cases of developed 
cholera. Towards the termination of an epidemic the proportion of 
deaths becomes small. 

Of the causes of cholera we know but little ; it may be said to pre- 
vail epidemically, though upon what this depends we know not, and 
this is not the place to enter into the nature of this epidemic influ- 
ence: it is but little controlled by climate; it infests chiefly low 
situations, and the banks of rivers. Its spread is favoured by impu- 
rities in the air and water, and therefore by bad ventilation and 
drainage, and by neglect of personal cleanliness, and apparently by 
the defect of ozone in the atmosphere of large towns ; by whatever, 
in fact, favours the spread of contagious diseases. Is it then conta- 
gious? — probably not highly so; but there can be no doubt that in 
many instances it has been conveyed by human intercourse. It 
affects mainly those in middle life, but no age is exempt. Debility may 
give some increased susceptibility, but the strongest and healthiest 
are not secure. 

There can be no stronger proofs of the great fatality of this disease, 
than the variety of remedies which have been announced as of certain 
efficacy, and of which the worthlessness of most, and the pernicious - 
ness of some, have been found to be as certain. In the treatment of this 
disease all theories must be discarded. Many opinions which have 
been entertained as to its essence might at first sight appear as harm- 
less as they are weak, were it not that they have been made the 
grounds of the most pernicious treatment. Of this kind is the 
notion that a material poison has got into the blood which must be 
driven out of it that recovery may take place. 

Now we have pointed out the fact of the morbid action which takes 
place in the intestinal mucous membrane, and have traced its fatal 
consequences : the obvious indications must be to restrain this, and 
not to aggravate it. In the commencement of the disease check the 
diarrhoea. This is best done by opium and astringents. If there be 
moderate diarrhoea let the ordinary combination (F. 97)* be employed, 
and enjoin strict rest, that is confinement to bed, or, if not, to a couch ; 
arrow-root and rice milk may be given, and if there be exhaustion 
let some brandy be added. If the diarrhoea increases, or if there be 
sickness, let a grain of calomel with one or two of opium, according 
to the urgency of the case, be given. If the choleraic symptoms 
appear to be setting in decidedly, give, in the first instance, half a 
drachm of compound chalk powder with opium, with half a drachm 

* (F. 97) R Confectionis Aromat. £iiss. 
Tinct. Catechu, 5 j. 
Tiuct. Opii, 3 ss — 3 i. 
Mist. Cretoe, 3 v. 

Aq. Cinnara. a sufficient quantity to make an 3 viii 
mixture of which 5J is to be taken after each fluid stool. 

38 



594 EPIDEMIC CHOLERA. 

of sal volatile in cinnamon water ; and if the diarrhoea be not checked, 
have recourse speedily to the calomel and opium, Many practitioners 
have a strong reliance upon calomel, and as it may help the capillary 
circulation, it is well to add it to the opium. The calomel and opium 
may be repeated, for the first three or four doses, every hour, and 
afterwards at longer intervals ; but when collapse is setting in with- 
draw the opium. If the astringent mixture has no effect, about a 
scruple of the extract of logwood may be added to each dose, though 
it is liable to the objection that by discolouring the stools it may mis- 
lead us as to the character of any change taking place in the evacu- 
ations ; or the gallic acid may be employed. (F. 98)* A saturated 
solution of gallic acid to the amount of about four ounces may also 
be injected into the bowel. We do not, however, place very much 
reliance upon enemata, since they are seldom retained, and the chief 
irritation is high in the small intestines. Thirst is an urgent symp- 
tom, and though water can rarely be retained, the patient may be 
allowed to drink freely, though not in large quantities at a time. 
When the pulse begins to fail, about a tablespoonful of brandy 
may be added to each tumbler of water. When the sickness is 
urgent, about four minims of dilute hydrocyanic acid, with half a 
drachm of compound spirit of ammonia, may be given in water 
every two or three hours. The latter is also a valuable adjunct to 
the diarrhoea mixture when there is much exhaustion. The placing 
a small piece of ice in the mouth often helps to check the sickness, 
and is a great comfort to the patient. 

The measures which we have recommended are intended to carry 
out the principle of averting the diseased action from the organ or 
tissue where that action is productive of the greatest mischief ; and 
we would apply the same rule to the skin, which is similarly 
affected with the mucous membrane. The surface is exceedingly 
cold, and therefore it has been attempted to raise the temperature 
by great artificial heat ; but this is as possible as it would be to 
warm a snow-ball without melting it. Any great heat and a load of 
blankets distresses the poor sufferer, and therefore it is best to con- 
sult his feelings in regard to clothes and temperature, though the 
apartment should be always carefully ventilated. We would not, 
however, by this, mean to forbid the application of large sinapisms 
to the abdomen, which may have the effect of stimulating the capil- 
lary circulation ; they are most beneficial at the commencement of 
the attack. 

When the collapse takes place we believe that we can do but 
little. Some practitioners have great reliance upon repeated small 
doses of calomel, but we must not forget, that scarce any medicines 
can be taken into the system when it is in this condition. We have 

* (F. 98) R Acid Gallici, zss, 

Tinct. Catechu, 3 j. 

Tinct. Opii, gss. 

Aq distillat. a sufficient quantity to make a ^vi. mix- 
ture of "which the one-sixth portion is to be taken every two hours. The laudanum 
must however be withdrawn when the collapse sets in. 



TREATMENT. 595 

generally been in the habit of giving about five grains of chlorate 
of potass with eight or ten of carbonate of soda in an onnce of vehicle 
every two hours, and a grain of calomel in the interval. If the pa- 
tient survive the collapse there is not uncommonly a distressing 
sickness with vomiting of green bilious matter. We have found 
the best remedy to be about five grains of calcined magnesia in half 
an ounce of water every hour and a half or two hours. After the 
sickness has subsided the chlorate of potass appears to act as a di- 
uretic, and helps to restore the capillary circulation. The secondary 
fever was, however, upon the whole, a most intractable disease, and 
even when the secretion of bile and urine appeared to be healthily 
restored many passed into a state of coma. The urine which was 
at first secreted was generally albuminous, but its becoming healthy 
did not insure .an escape from the comatose symptoms. 



596 INFLUENZA AND HOOPING COUGH, 



XXX. 

INFLUENZA AND HOOPING-COUGH. 

Influenza or epidemic catarrh is a disease which, requires only 
a short notice, although it is among the most fatal of epidemics ; but 
we have already anticipated much that is to be said respecting its 
treatment. It has been termed epidemic catarrh, from the affection 
which is its most frequent attendant, but we believe that the morbid 
influence* merely locates itself most commonly in the mucous 
membrane of the fauces and air passages, but it often affects other 
tissues as well. 

Influenza makes its attack generally with the symptoms of fever 
of an adynamic character. These are chills, rigours, extreme lan- 
guor and depression, afterwards reaction, which is, however, feeble. 
The tongue is covered with a creamy mucus ; the pulse quickened, 
rather sharp, but always compressible ; the skin is rarely very hot. 

In some cases, after reaction sets in, which may be in a few hours, 
the patient breaks out into a free perspiration, and if he be prudent 
and avoid exertion and exposure, the attack passes off. In most, 
however, there is severe catarrh, extending far into the bronchial 
tubes ; and when neglected or when occurring in debilitated sub- 
jects, leading to fatal bronchitis, or peripneumonia notha. In some 
cases the lung becomes inflamed, in others the pleura, in others the 
pericardium or endocardium. In some instances, again, the ence- 
phalon is attacked, and there are some of the symptoms of phrenitis. 
Cynanche is also a common complication of influenza ; so are some- 
times diarrhoea, dysentery, erysipelas, and a low form of arthritis. 

Influenza may be distinguished from common catarrh by the 
extreme debility; from mild fever by the extreme prostration, and 
in many cases by the appearance of an herpetic eruption around the 
mouth ; from ordinary attacks of the inflammation which are apt to 
complicate it ; by the tongue, the low form of the inflammation, and 
by the prevalence of the disease at the time. 

During the prevalence of an epidemic of influenza, an attack of 
that disease is always to be regarded with apprehension ; though in 
young and healthy subjects it is rarely fatal, unless some serious 
complication arises ; but unless great care be taken, it is very 
probable that some such will occur. In old and feeble persons 
the prognosis is always doubtful ; and if there be much tendency 
to chest-disease, unfavourable. 

In mild cases the best treatment is that of common catarrh. 
Where there is considerable depression, ammonia should be added 
to the saline, and a few grains of Dover's powder given at night, the 

* We are afraid of the term poison, lest it should suggest the attempt at some harsh 
method of eliminating; it. 



HOOPING COUGH. 597 

bowels being, of course, attended to. The treatment of the several 
complications must be that of those diseases themselves, with the 
qualification that the tendency is to asthenia, and that very few 
patients who are bled recover. And what is remarkable, in the in- 
fluenza of 1847, loss of blood was often followed by furious delirium. 



HOOPING-COUGH. 

This is an epidemic paroxysmal cough, mostly affecting children, 
the character of which is too generally known to need much descrip- 
tion. It generally begins with slight cough and difficulty of breath- 
ing, though often with but little signs of pyrexia; the cough by 
degrees assuming the well known " whoop," and being followed by 
expectoration of a quantity of mucus, and in many cases by sickness, 
after which the child will appear well, and express a desire for food, 
most of which is rejected after the next paroxysm. Sometimes, 
however, when the paroxysm has been a severe one, he is left 
languid and powerless. The disease may continue for weeks, or 
months, or for a year. The popular notion is that it lasts till the 
May following its invasion. 

Though children are the most frequently attacked by this disease, 
elderly and even old people have been often known to suffer from 
it. It perhaps depends upon a specific poison, and one attack 
generally insures an immunity for the remainder of life. It is 
generally believed to be contagious, and probably is so in some de- 
gree ; but it is certainly influenced by some epidemic temperament. 

The danger of the disease consists in its liability to be compli- 
cated with severe bronchitis and pneumonia ; and its remote ill 
effect, its proneness to induce dilated tubes or air cells. 

The treatment of hooping-cough, as long as it is simply such, 
should not be meddlesome ; as it is a nursery disease there are 
many nursery remedies, of which the most harmless is the best. 
Bland nutritious diet, and a uniform temperature, are indispensable. 
Medical superintendence is also necessary to watch for the occur- 
rence of the complications, which must be treated upon general 
principles. The combination of the conium mixture (F. 28) with a 
little dilute hydrocyanic acid ; two drachms of the mixture with 
one minim of the acid may be given to a child of four years 
old three times a day. After a time, if there be no fever, the 
ipecacuanha may be withdrawn, and the affection being spasmodic, 
zinc may be given, in doses of a quarter of a grain, in the intervals. 
Change of air, if possible to the sea-side, will generally complete 
the cure. 



598 DISEASES OF ADOLESCENCE AND PUBERTY. 



XXXI. 

DISEASES OF ADOLESCENCE AND PUBEKTY. 

The different periods of life are each more particularly obnoxious 
to different diseases, and this is ■ peculiarly the case with regard to 
youth and adolescence. We do not by this allude so much to the 
structural diseases of the sexual organs, the discussion of which, as 
regards the female, belongs more to the works of the obstetrician, 
and as regards the male, to those of the surgeon ; but to changes 
which take place in the relative proportions of the different parts of 
the body, at the period of puberty, which may be termed that of the 
transition from childhood, to manhood or womanhood. To this we 
have already alluded in reference to the development of tubercle. 
One great change which takes place at this time is in the relative 
size of the extremities and the trunk, and of the chest and the 
abdomen ; and the reason of this is, that as the extremities acquire 
their full proportionate development, there must be an increase in the 
quantity of blood sent to the right heart directly through the cavse, 
as compared with that which finds its way by the more circuitous 
route through the portal system ; at the same time there must be a 
demand for a greater activity in the decarbonising action of the lungs. 
This is remarkably shown as regards the latter by the observations 
of Andral and Gavarret, from which it appeared that in the male 
there was at the period of puberty a rapid increase in the volume of 
carbonic acid daily evolved by the lungs, that afterwards it continued 
slowly to increase till perfect manhood, and about the age of forty- 
five began to decline. Now the inference from this as regards the 
male subject is obviously this — that if the lungs themselves be un- 
sound, or if there be any causes impeding their development, as nar- 
rowing of the air passages, contraction of the chest from old pleuritic 
adhesions, or the effect of pericardial adhesion acting immediately 
through the impediment which it affords to respiratory movements ; 
or if there be obstructions to the pulmonic circulation, either from 
disease of the mitral valve or dilated bronchial tubes, or the effects 
of old bronchitis, it will be at this period that the effects of such 
defective development may be expected to show themselves, (see 
Guy's Hospital Eeports, 1st series, vol. vi., pp. 1, and 467,) and they 
will consist mainly either in disorganisation of the lungs, or enlarge- 
ment of the right heart, engorgement of the liver, ascites, and general 
dropsy. 

In the female, the progress of the activity of the respiratory func- 
tions is still more remarkable. In the girl it goes on increasing, as 
in the boy, to the age of puberty ; but when menstruation is esta- 
blished, instead of a further and more rapid increase, as in the male 
at the same age, the increase in the daily evolution of carbonic acid 



AMENORRHCEA. 599 

is arrested ; but should the catamenia be checked, there will be an 
increase in the evolution of carbonic acid until they are restored. 

We perceive, then, the important connection between the uterine 
functions and the organs of respiration, and also that if there exist 
any of those circumstances which have just been enumerated as pre- 
venting the development of the latter, an irregularity in the former 
must tend greatly to aggravate the ill effects which may be antici- 
pated. And that such is the case is confirmed by experience, cases 
having occurred in which, from early rheumatism and carditis, there 
had been narrowing of the mitral valve, menstruation became esta- 
blished, and the pulmonic obstruction was relieved, and the patient 
has gone on in tolerable health till the age when that function might 
be expected to cease, and then the dyspnoea, engorgement of heart 
and liver, and subsequent dropsy, quickly followed. 

Independently, however, of structural lesion, there appears in the 
female to be sometimes a want of power in the system to establish 
the catamenial function ; in other cases, again, it is arrested when so 
established. 

Hence we have two varieties of amenorrhcea, which are termed in 
the former case emansio mensium, and in the latter suppressio men- 
sium; but there is besides another distinction of equal or even greater 
practical importance, and that is between amenorrhcea with anasmia, 
and amenorrhcea in a plethoric subject. The former is termed 
amenorrhcea with chlorosis, and the latter simple amenorrhcea. 

Amenorrhcea with chlorosis, when appearing in the form of emansio 
mensium, is characterised by delayed development of the mammae 
and general anaemia; with suppressio mensium there may be full 
development. 

Amenorrhcea with chlorosis, then, is associated with anaemia, and 
is probably its effect ; the feeble powers of the system, as evinced by 
the deficiency of red corpuscles not being adequate to the supply of 
blood for the purpose. These cases are characterised by the white 
lips and white cheeks, with sometimes a sallow, greenish hue, the 
pearly conjunctivae, the dark areola round the eyes. There are com- 
monly dyspnoea and palpitation; there is an anaemic murmur in the 
ascending aorta, plainest, according to Dr. Hughes, where that vessel 
overlies the pulmonic artery. There is general weakness and inability 
for exertion, and the legs and feet are commonly oedematous towards 
night ; the nervous system is highly susceptible, and such patients 
are morbidly timid, and often hysterical. As an additional cause of 
weakness, there is often leucorrhoea. 

This form of amenorrhcea is most common in towns, and is no 
doubt much favoured by the want of pure air and sunshine. 

It must obviously be unreasonable to attempt to relieve such cases 
by any measures calculated directly to induce or restore the uterine 
functions, since their non-performance is often a conservative precau- 
tion on the part of nature, to save the power of the system. Iron, 
indeed, has the reputation of being emmenagogue ; but it is because 
it is tonic, and promotes the formation of red corpuscles, and the 
strength and material being given, the function is performed. The 



600 H Y S T E E I A. 

iron may be exhibited in the form either of ammonio-citrate or 
ammonio -tartrate, or the compound iron mixture of the Pharmacopoeia. 
The two former are the least offensive, and are not so apt to induce 
head-ache. They may be given in solution, and as the bowels are 
generally costive, some aperient pill should be given every night or 
every alternate night. For the latter reason an excellent form is the 
combination of the iron mixture with the compound decoction of 
aloes. Where there is much leucorrhoea, the solution of alum and 
zinc should be used as an injection per vaginam. 

In the cases of amenorrhcea without chlorosis, the cause of the non- 
performance of the function is probably dependent upon congestion. 
The subjects are generally florid, stout, full-bosomed girls, who, never- 
theless, have often a feeble circulation. Exercise, free purging, the 
application of a few leeches to the groins or to the inside of the 
thighs, when the period comes round, are the best remedies. Many 
practitioners have faith in the madder and hellebore as emmenagogues. 

Hysteria is another affection closely connected with uterine derange- 
ment in females, it is from thence that it derives its name. To de- 
scribe its various phases, would exceed our limits ; there is no disease 
which it may not simulate, but it should be * remembered that there 
is none which it may not mask. The well-known hysteric fits are 
perhaps the effect of excessive polarity of the spinal cord, that of the 
brain being diminished ; such a state of things is more apt to exist in 
the female than the male, especially if there be a tendency to chloro- 
sis ; and when we consider the vast supply of nerves distributed to 
the uterus, we cannot be surprised at the ready excitement of spasm 
or convulsion from irritation of that organ. Another remarkable 
phenomena in hysteria is a strange perversion of the moral feelings, 
evincing its presence in fondness for simulation. Thus delicate fe- 
males will not only feign disease of the bladder, rectum, or uterus, 
but even some which may subject them to painful operations. Some- 
times, again, there is a species of delirium, of which one of the most 
remarkable characteristics is that young females, often young ladies, 
will use obscene expressions, and sometimes sing songs with which 
we could hardly believe that they were acquainted. 

In the management of hysteria we must look first to the natural 
functions, and especially those of the bowels and the uterus, and there 
are few better remedies during the paroxysm, than cold effusion. 

In the intervals of the paroxysms, the valerianate of zinc, in doses 
commencing at about a grain, and gradually increased, will often 
have the effect of preventing them. 

In the hysteric mania the combination of camphor and henbane, 
and the occasional use of assofcetida injections, will be very service- 
able. After the maniacal excitement has subsided, the valerianate, or 
sulphate of zinc may be employed; but more important than these 
are moderate exercise for the body, and rational employment for the 
mind. "We have already hinted that in several spasmodic diseases 
the automatic functions are in undue action, whilst the voluntary 
power is in abeyance ; and this is the case in hysteria ; but beyond 
this, there is an increase in the emotional susceptibilities, and dimi- 






HYSTERIA. 601 

mition in the controlling power of the reason. To subdue the former, 
and strengthen the latter, should therefore be a leading object. For 
this reason, moderate intellectual exercise is to be encouraged ; but 
the stimulus of much that is termed light literature is to be discoun- 
tenanced. Rational society is to be sought, but dissipation shunned. 
Religion, in its truest sense, is as healthful, as sentimental religionism 
is pernicious. 



INDEX 



Abscess, 56. 

Acid, phosphoric, in urine, 410. 

uric, 405. 

Adolescence, diseases of, 597. 

Ague, 485. 

Albumen in the urine, tests for, 380. 

of the blood, changes in, 33. 

Amenorrhoea, 498. 

Anaemia, 30. 

Anaesthesia, 466. 

Antimony, tartarized, action of, 99, 

in pneumonia, 199. 

Anorexia, cause of, 326. 
Aortitis, 288, et seq. 
Aorta, aneurism of, 289. 

diagnosis of, 292. 

treatment of, 292. 

Aortic valves, disease of, 261, 280. 

treatment of, 361. 

Apncea, death from, 26. 
Apoplexy, 450. 

different forms of, 451. 

pathology of, 452. 

its remote causes, 456. 

its diagnosis and treatment, 457, 

et seq. 
Appetite, loss of, 78. 
Ascites from chronic peritonitis, 352, 

355. 

hepatic, 290. 

treatment of, 304. 

Asthenia, death from, 82. 
Asthma, 481. 
Auscultation, 129, et seq. 



Biliary calculi, 309. 
Blood, changes in, 30. 

coagulation of, 32. 

foreign ingredients in, 36. 

effects of retained secretion on, 34. 

buffy coat, 32. 

inflamed, 60. 

Blood-letting, topical, 86. 
Bleeding, effects of, 88. 

indications for, 88, et seq. 

Bowels, inflammation of, 356. 
obstruction of, 358. 



Brain, disease of arteries of, 453. 
— — congestion of vessels of, 453. 

inflammatory diseases of, 419. 

disease of, from affection of 



kid- 



neys, 393. 

Bright's disease, different forms of, 386. 
Bronchitis, acute, symptoms of, 168. 

— character of expectoration in, 



171. 



— modes of fatal termination of, 



172, et seq. 

diagnosis of, 174. 

prognosis of, 176. 

treatment of, 177, et seq. 



chronic, 181. 

its treatment, 



184. 



Bronchial tubes, dilated, cause of, 182, 

et seq. 
Bronchophony, pneumonic, 135, 191. 
Broncho-pneumonia, 224. 
Broncho-Pleuro-pneumonia, 226. 
Buffy coat, 32. 

Calculus in the ureter, 384. 
Cancer of stomach, 320. 
Carditis, 255. 
Catarrh, 164. 

■ treatment of, 167. 

prevention of, 167. 

epidemic, 595. 

Cerebral inflammation, 419. 
Cerebro-spinal meningitis, 433. 
Changes, elementary, 29. 
Chicken-pox, 538. 
Child-crowing, 154. 
Chlorosis, 498. 
Chorea, 471. 
Cholera, English, 370. 

epidemic, 590. 

infantum, 373. 

Circulation, derangements of, 36. 

Cirrhosis of liver, 301. 

Colchicum, use of, in rheumatism, 1 

119. 
Cold, use of, 100. 
Colica pictonum, 483. 
Colic, 482. 
painter's, 433. 



604 



INDEX. 



Coma, death from, 27. 
Congestion, active, 36. 

passive, 38. 

mechanical, 39, 43. 

treatment of, 39. 

Constipation, obstinate, its causes, 359. 

diagnosis of, 360. 

Convulsions, infantile, 471. 
Corpuscles, blood, changes in, 30. 
Counter-irritants, use of, 104. 
Crepitatio redux, 192. 
Crepitation, moist, 192. 

pneumonic, 189. 

Croup, 150. 

premonitory signs of, 150. 

symptoms of, 152. 

varieties of, 153, 154. 

spasmodic, 154. 

diagnosis of, 156. 

treatment of, 159. 

catarrhal, 154. 

mucous, 154. 

spasmodic, 154. 

Cynanche, 138. 

treatment of, 140. 



Death, modes of, 24. 

from coma, 24. 

from syncope, 25. 

modes of, in inflammation, 82. 

Delirium tremens, 443. 

its causes, 444. 

Deposits, typhous, 106. 

scrofulous, 107. 

urinary, 405.. 

Diabetes, 416. 
Diaphoretics, use of, 98. 
Diathesis, tuberculous, 110. 
Diarrhoea, 369. 

varieties of, 369. 

Digitalis, action of, 100. 
Disease, general signs of, 65. 

causes of, 18. 

endemic, 22, 

epidemic, 22. 

hereditary, tendency to, 19. 

Diuretics, use of, 96. 
Dropsy, 290, 325, 352, 390. 

of the brain, 424. 

Dysentery, 370. 
Dyspepsia, 326. 

treatment of, 331. 

symptoms of, 326. 



Effusion, inflammatory, 50. 

pleuritic, signs of, 211. 

diagnosis of, 214. 

Empyema, 207. 

EnceDhalon, inflammatory diseases of, 
419. 



Encephalitis, 419. 
Endemic diseases, 22. 
Endocarditis, 259. 

anatomical changes in, 259. 

signs of, 259, 260. 

causes of, 263. 

diagnosis of, 264. 

fatal termination of, 265. 

treatment of, 265. 

chronic, 270. 

Enteritis, 356. 
Epidemic diseases, 22, 
Epilepsy, 474, et seq. 

its pathology, 475. 

causes and diagnosis, 476. 

treatment of, 478. 

Erysipelas, 549. 
— — causes of, 551. 
treatment, 552. 



Fever, inflammatory, 61. 

hectic, 62. 

eruptive, 530, et seq. 

intermittent, 485, 488. 

Fever, intermittent, causes of, 487. 

complicated, 497. 

treatment, 494. 

remittent, 498. 

continued, 485, 501. 

its symptoms, 501. 

varieties of, 503. 

complications of, 504. 

muculse in, 508. 

pulse in, 510. 

prognosis, 512. 

modes of death in, 512. 

treatment of, 515. 

use of wine in, 524. 

complicated, treatment of, 527. 

yellow, 554. 

Fibrine, changes in quantity and qualitv 
of, 30. 



Gall Ducts, inflammation of, 305. 

treatment of, 306. 

Gall-stones, 309, 310. 

Gangrene, 59. 

Gastritis, acute, symptoms of, 315. 

cause of, 315. 

diagnosis of, 316. 

treatment of, 317. 

— — chronic, 318. 

terminations of, 318. 

causes of, 318. 



— — treatment of, 319. 
Glottis, oedema of, 147. 
Gout, acute, 122. 

chronic, 123. 

treatment of, 126. 

Goutv diathesis, 123. 






INDEX. 



605 



Hjsmatemesis, 322. 
Haemoptysis, 232, 236, 241. 

treatment of, 250. 

Heart, diseases of the, 255. 

hypertrophy of, 271. 

dilatation of, 271. 

hypertrophy of, true, 272. 

hypertrophy and dilatation of, 273, 

280. 



hypertrophy of, false, 274. 

fatty degeneration of, 274. 

hypertrophy of, false, diagnosis, 276. 

disease of, from affection of kidneys, 

392. 
Heartburn, 335. 
Hectic fever, 62. 
Hepatitis, 297. 
Hepatization, pneumonic, 1 90. 

grey, treatment of, 201. 

Hooping cough, 596. 
Hunger, its nature, 78. 

as a sign of disease, 78. 

Hydrocephalus, acute, 424. 

its symptoms, 425. 

its causes, 426. 

its diagnosis, 426. 

its treatment, 428. 

chronic, 432. 



Hyperemia, active, 36. 

passive, 38. 

Hysteria, 599. 



Ileus, 358. 
Indigestion, 326. 
Inflammation, 44, et seq. 

description of, 44. 

state of vessels in, 45. 

nerves in, 48. 

consequences of, 48, 49. 

blood in, 46, 60. 

signs of, 65. 

effusions of, 50. 

metastasis of, 49. 

resolution of, 49. 

its fatal terminations, 82, et seq. 

principles of treatment of, 82, et seq. 

blood-letting in, 86, et seq. 

gouty, 121. 

rheumatic, 115. 



Inflammatory lymph, 52. 

process, review of, 63. 

Influenza, 595. 

Intestine, obstruction of, diagnosis, 360. 



Jaundice, 307. 

symptoms of, 308. 

causes of, 309. 

a fatal form of, 311. 

treatment of, 312. 



Kidneys, diseases of, 378, et seq. 

acute inflammation of, 383. 

Bright's disease of, different forms 

of, 386. 

affection of heart in, 390. 

brain in, 393. 

lungs in, 392. 



— spasmodic affection in, 393. 

— changes of blood in, 390. 

— Bright's disease of, its history and 
symptoms, 394. 

its dignosis, 395. 

its causes, 397. 

its treatment, 398, et seq. 



Laryngismus stridulous, 154. 
Laryngophony, 135. 
Laryngitis, 142. 

acute, treatment of, 144. 

chronic, 148. 

Lemon-juice, use of, in rheumatism, 

119. 
Leucorrhcea, 488. 
Lime, oxalate of, 408. 

phosphate of, 409. 

Lithates, deposits of, 407. 
Lithic acid deposits, 407. 
Liver, diseases of, 293. 

congestion of, 293. 

gangrene of, 300. 

inflammation of, 297. 

inflammation of, suppurative, 297. 

abscess of, 297. 

diagnosis of, 299. 

adhesive inflammation of, 300. 

cirrhosis of, 501. 

pathology of, 301. 

inflammation of veins of, 304. 

inflammation of ducts of, 305. 

Lung, gangrene of, 192. 

malignant disease of, 242. 



Lymph, fibrinous, 50, 51. 

corpuscular, 51, 52. 

inflammatory, 52, 53. 



Mania, acute, 447. 

Mania-a-potu, 443. 

Measles, 539. 

Medicine defined, 17. 

Melama, 324. 

Meningitis, cerebro-spinal, 433, 

Mercury in inflammation, 101. 

in pneumonia, 199. 

action of, 101. 

Metastasis, 49. 

Mitral valve, disease of, 262. 280. 

treatment of, 287. 

Muco enteritis, acute, 365. 
chronic. 366. 



606 



INDEX. 



Nerves, in inflammation, 48. 
Nephralgia, 384. 
Nephritis, acute, 383. 

treatment of, 385. 

diagnosis of, 384. 



OESOPHAGITIS, 313. 

(Esophagus, diseases of, 313. 

• stricture of, 313. 

Opium, its use in fever, 522. 
Ovaries, irritation of, 341. 
Oxalate of lime, 408. 



Pain, as a sign of disease, 65. 
Painter's colic. 483. 
Palsy, lead, 483. 
Paracentesis, 222. 
Paralysis, facial, 466. 

its causes and treatment, 460, et seq. 

Paraplegia, 464. 
Pectoriloquy, 135. 
Peritoneum, disease of, 336. 
Peritonitis, chronic, 347. 
■ — — tuberculous, 348. 

chronic, diagnosis, 350. 

its diagnosis and prognosis, 342, 

343. 

■ fatal termination of, 342. 

puerperal, 345. 

— — acute, its treatment, 344. 

chronic, its treatment, 353. 

subacute, 353. 

acute, 336. 

its pathology, 336. 

'■ — its symptoms, 337. 

its causes, 339. 

Pericarditis, acute, 255. 

chronic, symptoms and treatment 

of, 269. 

fatal termination of, 265. 

Pericarditis, treatment of, 266. 
Peripneumonia notha, 224, 
Pertussis. 596. 
Phosphates in urine, 411. 
Phosphatic deposits, diagnosis of, 412. 

microscopic characters of, 413. 

Phosphates, causes of deposition of, in 

the urine, 414. 
Phrenitis. symptoms, 420. 

diagnosis of, 421. 

treatment of. 422. 

Phthisis, 227. 

anatomical changes in, 227. 

varieties of, 230. 

stages of, 230. 

complications of, 236. 

acute, 238. 

fatal termination of, 240. 

diagnosis of, 241. 

treatment of, 243. 



Phthisis, abdominal, 368. 
Plethora, 30. 
Pleuritis, 205. 

treatment of, 220. 

pathology of, 205. 

causes of, 215. 

symptoms of, 207. 

prognosis of, 218. 

Pleuro-pneumonia, 225. 
Pneumonia, pathology of, 186. 

anatomical changes in, 186. 

its symptoms, 188. 

■ diagnosis of, 193. 

prognosis of, 194. 

fatal terminations of, 196. 

causes of, 197. 

treatment of, 198. 

treatment in second stage, 200. 

typhoid, 203. 

in complication with fever, 527. 

in children, 194. 



Pneumonia notha, 224. 
Pneumothorax, 216. 
Poisons, effects of, 27, 28. 
Predisposing causes of disease, 18. 
Puberty, diseases of, 597. 
Pulse, conditions requisite for a healthy. 
68, 69. 

irregular, 69. 

feeble, 69, 71. 

splashing. 69. 

thrilling, 70. 

circumstances which affect it, 71. 

effect of nervous influence of, 72. 

frequency of, 72, 73. . 

characters of, 73. 

its force or feebleness, 74. 

Purgatives, use of, 95. 
Puriform infection, fatal, 83. 
Purp urine, 408. 
Pyrosis, 329, 335. 



Rattles, mucous, causes and varieties 

of, 171. 
Resolution of inflammation, 49. 
Rheumatism, acute, 115. 

subacute, 116. 

diagnosis of, 117. 

treatment of, 117, et seq. 



Ronchus, nature and cause of, 134, 170. 
Rubeola, 539. 



Scarlatina, 541. 

simplex, 542. 

anginosa, 542 

maligna, 543. 

treatment. 546. 



Scrofulous deposit, 107. 

Secretions, retained, effects of, 33, 34. 



INDEX. 



607 



Sedatives in inflammation, 98. 
Sibilus, nature and cause of, 133, 170. 
Small pox, 531. 

distinct, 532. 

confluent, 533. 

modified, 537. 

Syncope, death from, 25. 
Spaneemia, 30. 

Spasm, its nature and causes, 468. 
Sporadic diseases, 20. 
Stomach, diseases of, 315. 

malignant disease of, 320. 

causes of, 321. 

treatment of, 322. 

Sugar, tests for, in urine, 417. 
Sulphates in urine, 409. 
Summer complaint, 373. 
Suppuration, 55, 56. 
Symptoms of disease, secondary, 68. 

general, 68, 69. 

Syncope, death from, 25, 82. 



Tabes Mesenterica, 368. 
Tenderness, as a sign of disease, 66. 
Thirst, its cause, 77. 

as a symptom of disease, 78. 

Tongue, signs afforded by, 75. 
Tonsillitis, 138. 
Tubercle, 107. 

origin of, 108. 

■ development of, 108. 

■ laws which regulate deposition of, 

112. 



Tuberculous deposit, 107. 

diathesis, 108. 

Typhoid Fever, 509. 
Typhous deposit, 106. 
Typhus Fever, 485, 509. 



Ulceration, 58. 

fatal termination of, 83, 84. 

Urates, deposits of, 406. 
Urinary deposits, 405. 
Uric acid, deposits of, 405. 
Urine, cause of its acidity, 405. 

sulphates in, 409. 

phosphates in, 410. 

alkaline, 411. 

changes in, 378. 

blood-matter in, 379. 

_. — _ tests for albumen in, 380. 



Vaccination, 536. 

Vaccine vesicle, description of, 536, 

Valves, diseased, g80. 

, ___„ fatal termination, 283. 

. treatment of, 284. 

Varicella, 538. 
Variola discreta, 532. 
■ confluens, 533, 



Water-brash, 329, 335. 
Yellow-fever, 554. 



V 



£ 90 6" 






